Introduction: The Lord Bishop of Carlisle

The Lord Bishop of Carlisle—Geoffrey Graham, Lord Bishop of Carlisle, was introduced between the Lord Bishop of London and the Lord Bishop of Winchester.

Human Fertilisation and Embryology Bill [HL]

Lord Darzi of Denham: My Lords, I beg leave to introduce a Bill to amend the Human Fertilisation and Embryology Act 1990 and the Surrogacy Arrangements Act 1985; to make provision about the persons who in certain circumstances are to be treated in law as the parents of a child; and for connected purposes. I beg to move that this Bill be now read a first time.
	Moved accordingly, and, on Question, Bill read a first time, and ordered to be printed.

Regulatory Enforcement and Sanctions Bill [HL]

Lord Bach: My Lords, on behalf of my noble friend Lord Jones of Birmingham, I beg leave to introduce a Bill to make provision for the establishment of the local better regulation office; for the co-ordination of regulatory enforcement by local authorities; for the creation of civil sanctions in relation to regulatory offences; for the reduction and removal of regulatory burdens; and for connected purposes. I beg to move that this Bill be now read a first time.
	Moved accordingly, and, on Question, Bill read a first time, and ordered to be printed.

Business

Lord Grocott: My Lords, as regards an advisory time limit for speeches, the situation is a bit easier than yesterday. We have a target rising time of seven o'clock and more than 30 speakers, but we shall easily accommodate them if the Back-Bench speeches are no longer than 12 minutes. That is not a bad length of time.

Debate on the Address

Debate resumed on the Motion moved on Tuesday last by the Baroness Corston—namely, That an humble Address be presented to Her Majesty as follows:
	"Most Gracious Sovereign—We, Your Majesty's most dutiful and loyal subjects, the Lords Spiritual and Temporal in Parliament assembled, beg leave to thank Your Majesty for the most gracious Speech which Your Majesty has addressed to both Houses of Parliament".

Lord Darzi of Denham: My Lords, this Government have a proud record of improving health and education services. We have increased resources, from £35 billion in 1997 to more than £90 billion in 2007, rising to £110 billion by 2010-11. We have improved services. Extra staff and investment have led to improved patient outcomes, as Derek Wanless recognised in his recent report. Mortality rates from cancer are down by 17 per cent and from cardio vascular diseases by 35 per cent. More than 1 million extra operations take place every year. Waiting lists are down while satisfaction levels are up. One hundred new hospitals are benefiting from state of the art equipment.
	It is a similar story in education: 1,558 Sure Start children's centres have been established so far, offering services to well over 1 million young children and their families. More than 60 per cent of our 15 year-olds are now achieving five good GCSEs and the number of schools where more than 70 per cent of pupils gain at least five good GCSEs has gone up tenfold from just 83 in 1997 to 857 in 2007. The number of young people participating in apprenticeships is at a record level with more than a quarter of a million now in learning—up from 75,000 in 1997.
	In my recent interim report of the NHS Next Stage Review, I set out a vision for a world class NHS that focuses relentlessly on improving the quality of care. One of the key components of quality is that the system is safe. It should be as safe as it possibly can be, giving patients and the public the confidence they need in the care they receive.
	The Health and Social Care Bill will be introduced into Parliament shortly. It will do much to ensure the safety and quality of services. I must declare an interest here as a practising clinician. The Bill will create a new integrated regulator of health and adult social care, which will focus on providing assurance of the safety and quality of care for patients and service users. The creation of a new regulator—the Care Quality Commission—will bring together the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. The regulator will have tougher powers to inspect, investigate and intervene where hospitals and care providers are failing to meet hygiene and other safety and quality requirements. The commission will also have new powers to apply a consistent approach to regulation, by requiring providers of health services and adult social care, both public and private, to register with it.
	As well as improving the regulation of the NHS and the adult social care system, the Bill will enhance professional and public confidence in the regulation of healthcare professionals and social care workers. Following the publication of the White Paper on professional regulation and the government response to the Shipman inquiry, the Bill introduces a number of measures to improve professional regulation. The Bill introduces a new set of public health measures to help to prevent or control the spread of infection or contamination. The measures in the Bill willbalance the need to restrain activities where they could present a threat to public health with the need to respect individuals' rights. The Bill will also create the health in pregnancy grant, which will be a one-off payment to all expectant mothers ordinarily resident in the UK.
	I spoke earlier of new services and new challenges. Nowhere is the pace of change greater than embryology. The Human Fertilisation and Embryology Bill will help to maintain the UK's position as a world leader in groundbreaking research for the treatment of serious diseases, including through embryonic stem cell research. The Bill's provisions represent an overhaul of the existing law, the Human Fertilisation and Embryology Act 1990, taking account of developments both in technology and in attitudes, and will promote public confidence together with best regulatory practice.
	That is not to say that the existing system has broken down or that it has not been successful. On the contrary, the regulatory framework put in place in 1990 has proven to be robust in the face of challenges. It is a tribute to Parliament, and to several Members of your Lordships' House in particular, that this is the case. The regulator—the Human Fertilisation and Embryology Authority—has also performed well.
	We have therefore kept to the fundamental underpinnings of the regulatory scheme based on the report of the Committee of Inquiry chaired by the noble Baroness, Lady Warnock, on which the 1990 Act was based. Nevertheless, technology has moved on, and so have attitudes. There are, for example, novel ways of creating embryos for research, a much-increased capacity to screen embryos for serious genetic diseases and, at the same time, a legal recognition for different family forms. Those developments demand an examination of the legal and regulatory framework through parliamentary debate, and a resetting of the relevant parameters for the future. The Government published their proposals for updating the law in their December 2006 White Paper. That was followed by publication of the Bill in draft form, which was then titled the Human Tissue and Embryos Bill. The change in the title of the Bill reflects the Government's decision not to proceed with a proposal to merge the HFEA with the Human Tissue Authority.
	The key aims of the Bill are to ensure that all human embryos outside the body—whatever the process used in their creation—are subject to regulation; to clarify the regulation of "inter-species" embryos for research; to impose a statutory ban on the sex selection of offspring for non-medical reasons; to recognise same-sex couples as legal parents of children conceived through the use of donated sperm, eggs or embryos and to increase the scope of legitimate embryo research activities, subject to controls. These are issues on which a range of views are sincerely held.
	The Children and Young Persons Bill and the Education and Skills Bill provide a framework for young people. We want to increase participation in learning and improve life chances for all children. This Children and Young Persons Bill is designed to make those ambitions a reality for some of the most vulnerable children in our society—children in care. As achievement figures soar to record levels, children in care, by contrast, are five times less likely to achieve five good GCSEs and nine times more likely to be excluded from school. More than 30 per cent of former care leavers are not in education, employment or training at age 19, compared with 13 per cent of all young people. They are less likely to progress into higher education and more likely to end up in prison.
	It is our responsibility to improve the educational and care experience of young people looked after by the state. We all share this responsibility—to look out for these young people, to support them, as we would our own children. Following a Green Paper and extensive consultation over 18 months, the Government's Care Matters White Paper set out the reforms needed to transform the life chances of children and young people in care.
	It is built on four central principles: high ambitions for children in care—we want those who enter the care system to achieve the aspirations we have for our own children and we need to reduce the achievement gap between children in care and their peers; addressing the challenges of parenting within a complex system of different services and, in doing so, addressing the educational, social and health problems which children in care experience; greater placement stability and more consistency for children in care, so they are not uprooted and moved around before they have had the chance to settle in a school or make friends—currently children can go through as many as nine or 10 placements within two years and see as many as 30 social workers; and making sure children in care can have their say in important decisions that affect their life.
	These four principles have guided the Government in deciding to legislate to: enable local authorities to test a different model of social care by delegating social care functions to social care practices; increase the focus on the transparency and quality of care planning—in particular, by strengthening the role of the independent reviewing officer; increase schools' capacity to help children in care by placing the role of the designated teacher on a statutory footing and ensuring that children in care do not move schools, particularly in GCSE years, except in exceptional circumstances; ensure that young people up to 18 are not forced out of care before they are ready, by giving them a greater say over moves to independent living and ensuring they retain support and guidance as long as they need it; and limiting "out of authority" placements, securing higher placement standards and ensuring children in care in custody are visited regularly. I am pleased that there has been considerable consensus around many of the proposals in the Bill and about how we achieve that aim.
	The second Bill to be introduced jointly by DCSF and DIUS is the Education and Skills Bill. It will increase participation in learning for young people and adults, driving towards the Government's aim of a country with world-class skills by 2020. The legislation will ensure that more young people participate in education and training, post 16. We will go beyond our current aspiration of 90 per cent participation among 17 year-olds by 2015 to reach the 10 per cent of young people—often the most vulnerable—who would still not be reaping the benefits of formal accredited learning.
	This is not about requiring young people to stay in school. Our wider 14 to 19 reform programme is putting in place an attractive package of post-16 learning routes including the new diplomas, which will bridge the historical divide between vocational and academic qualifications. In future, our 16 year-olds will be able to choose a number of ways to participate: through full-time education in school, at college or at home; on a work-based learning programme, such as an apprenticeship; or part-time alongside employment or volunteering that takes more than 20 hours a week. We believe that this will provide all young people with the opportunity to participate, whatever their background, whatever their goals in life.
	However, an element of compulsion is important if we are to reach those young people who, whatever options the Government put in place, will not participate voluntarily because they do not recognise the longer-term benefits of improving their skills. It will galvanise the education system to prepare every young person to participate. The new duty to participate will be backed up by a comprehensive system of information, advice and guidance, not just for young people, but for parents and carers so that they are in a better position to encourage the most appropriate form of learning.
	As a step towards ensuring that the organisations closest to local provision and individuals' needs are in a position to advise, this Bill will transfer to local authorities responsibility for the careers advice and guidance services currently delivered by Connexions. To back this up, the Bill will introduce national standards for information, advice and guidance provided by local authorities. More than 70 per cent of the UK's working-age population in 2020 will already be over the age of 16. That makes enabling low-skilled adults to re-engage with and access learning a crucial task in ensuring the UK's economic and social health.
	Responding to the recommendations in the Leitch review of the UK's skill needs, the Bill promotes increased participation and achievement among people over 18 years of age. It will put in place a statutory framework to enable all adults with low skills access to the basic platform for employability, basic literacy and numeracy skills, leading to a first full level 2 qualification. For those between 19 and 25 years-old, it will provide free training towards a first full level 3 qualification.
	The Bill is a landmark in education, comparable with the Butler Act of 1944. It is now more important than ever before that we improve the skills base in this country and tackle the tail of underachievement among young people and adults alike. The Government's legislative proposals are aimed not just at economic productivity. Increasing skill levels is crucial to improving an individual's life chances and to the Government's wider goal of social justice for all. The Bill is about changing the expectations in a system where it is still acceptable for young people to leave education and training at 16, never to return.
	I turn, finally, to the Sale of Student Loans Bill which is being introduced by the Department for Innovation, Universities and Skills. It is an enabling Bill, which gives the powers needed to embark on a programme of sales from the income-contingent student loan book. The student loan book is a considerable asset, currently around £18 billion. It is set to grow very significantly over the next decade, so it is right that the Government think carefully about how that asset fits within the overall policy on public finances. Making sales from the student loan book fits with our established policy of not retaining assets in the public sector unless to do so fulfils a public policy purpose. Retaining the loans in the public accounts exposes the Government to the risks associated with the uncertainties surrounding the repayment of very large amounts of money. It is not usual government business to remain exposed to large amounts of debt-related risk and we believe that the private sector is well placed to take on and to manage those risks.

Lord Higgins: My Lords, it is not apparent that there are lessons to be learnt from the present situation in financial markets? Is the Minister proposing that the Government securitise student loans that may well turn out not to perform?

Lord Darzi of Denham: My Lords, the noble Lord raises the issue of security, and I am sure it will be debated during the passage of the Bill, which is an enabling Bill as I said earlier. I shall make that point as I go through the remainder of my speech.
	It is not usual government business to remain exposed to large amounts of debt-related risk, and we believe that the private sector is well placed to take on and manage those risks. The Bill will enable us to put in place that programme of sales, making transactions that are judged to deliver good value for money for the taxpayer. It is, however, an enabling Bill. It does not require us to make sales, let alone constrain us as to when or how much to sell. The Government will ensure that they benefit from the highest quality commercial and legal expertise in designing the sales programme and in preparing each individual transaction. I hope that reassures the noble Lord. For each transaction, we will need to be satisfied that market conditions enable us to secure good value for money for the taxpayer.
	The ownership of the rights to the loan repayments that graduates make does not affect how we design and deliver policy on student support. It is central to the Government's policy that borrowers with student loans should experience no difference whether their loans are sold or retained in the public sector. Purchasers of loans will not be able to alter the terms and conditions. They will not be able to change interest rates, repayment thresholds or rates of repayment. The Bill enables us to ensure that if the Secretary of State changes the terms and conditions of existing loans, that will affect sold loans in just the same way as those still in the public sector. The administration of the income-contingent repayment system, with collection by Her Majesty's Revenue and Customs through the tax system and the maintenance of borrower accounts by the Student Loans Company, will remain as now for all loans. Borrowers' data will be fully protected and their experience of the system will be the same whether their loan is sold or not.
	The Sale of Student Loans Bill is not about altering policy on student support. It is not about converting student loans into commercial loans. The Bill is rather about enabling the transfer of ownership and risk of the underlying financial asset, while expressly leaving individual borrowers and the system of student support in the same position as before.
	The Government are passionate about quality, be it in the NHS, social care, embryology, children's welfare, developing skills or student loans. Improving quality in these areas is challenging, and these Bills are crucial in rising to that challenge. I commend this legislation to the House and look forward to the important and, no doubt, vigorous debates ahead.

Earl Howe: My Lords, it is a pleasure to follow the excellent and very stimulating opening speech by noble Lord, Lord Darzi. I know that the House will be grateful to him for preparing the ground so ably for a debate that is inevitably going to prove fairly wide-ranging. The subject matters of today's debate are health, social affairs and education. I am not even going to attempt to cover the full extent of those policy areas. My noble friend Lady Morris will concentrate at the end on issues relating to education and children and I shall focus, in my brief set of remarks, on health and social care.
	We live in strange times. Whenever I think of the noble Lord, Lord Darzi, I heave a sigh of relief that somebody sensible is looking at health policy across the piece and is doing so from the point of view of the patient to see what is best to meet patient needs. We have high hopes of what he will tell us when he reports next year, although nobody underestimates the scale of his task.
	In the mean time, the Minister has inherited an NHS that is far from being the happy and cheerful scene that some of his colleagues like to present to us. First, there are the NHS finances. The year before last, 2005-06, the NHS ran up a net deficit of over £0.5 billion, so enormous efforts were devoted to reining in the finances in the year that followed. The outturn in 2006-07 was a net surplus of £0.5 billion, although within that figure almost a quarter of NHS organisations finished the year in deficit.
	My noble friend Lord James will enlighten us further on this whole subject, as he is so ably equipped to do. I hope that he will agree with me on a key point, which is that the surplus recorded last year was largely illusory. It was achieved only by dint of savage cuts to training and education budgets by strategic health authorities and by raiding public health budgets. Budgets for buildings maintenance were also heavily raided. When the outturn for the year was announced, Ministers patted themselves on the back for having saved a lot of money. However, if we look at how they achieved it, not many of us think that it is a cause for congratulations.
	A similar point could be made about waiting time targets. Reducing waiting times is important and needs to be measured, but we need to remember that the target relates only to a fraction of NHS activity. The mammoth effort being devoted to bringing down waiting times distorts clinical priorities, not least because it tends to suck money in from other areas of healthcare which are not subject to targets, such as chronic long-term conditions and follow-up, emergency and maternity care.
	After Gordon Brown's announcement in the summer that the Government would be doing away with top-down targets from Whitehall, it is somewhat extraordinary that the biggest target of the lot—the 18-week referral to treatment target—is still something that Ministers are pursuing so doggedly.
	Labour Ministers often claim that this is the first Government to recognise and to tackle health inequalities. I happen not to agree with that. But how are they doing it? One of the public service agreement targets in 2004 was to reduce health inequalities by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth. Using the figures that we have so far, both measures have got worse, not better—that is to say, worse in terms of the gap that exists between the least affluent groups in society and the population as a whole. Again, the constant raiding of public health budgets cannot possibly be conducive to achieving these targets.
	What about staffing? Last spring we had the debacle over modernising medical careers. It is doubtful whether any policy failure in the last 60 years has had such a devastating effect on the morale of medical staff as the failure of MTAS. The criticisms levelled at the Government by Sir John Tooke make pretty devastating reading. MTAS has been abandoned but, if anything, competition for training places looks set to be even fiercer next year than it was this year. At PCT level, the Healthcare Commission survey has found over the past four years steadily declining levels of job satisfaction.
	Where are we now heading? In July, the Prime Minister gave his vision of the health service by promising,
	"to put power in the hands of patients".—[Official Report, Commons, 11/7/07; col. 1450.]
	I have to say, looking at the gracious Speech, that it is hard to identify anything that is designed to take us noticeably in that direction. One might have expected to see something about individual budgets to give patients direct control over their own social care. We have been promised that for about two years, but so far we have not got beyond the pilot stage. As it is, we have the promise of the Health and Social Care Bill.
	There is nothing wrong with the idea of creating a single regulator for health and social care out of those that exist at the moment; indeed, I remember that when we first debated the creation of CHAI and CSCI I advocated just that. However, one thing we can be clear about: there is bound to be disruption in the regulatory process. If we want a recent lesson in how mergers cause operational disruption, we need only look at PCTs. The Healthcare Commission's annual health check for 2006 reported that out of all the healthcare bodies, reconfigured PCTs came out worst on quality of services.
	Some of us fear that within the new, all-encompassing regulator, the dominant activity will be the regulation of healthcare and that the regulation of social care will emerge as the poor relation. That may happen for a number of reasons, not the least of which is that the business of regulating healthcare has a much higher public profile and will tend to suck funding away from other activities. There are three main ways in which that can be avoided: the way in which Ofcare's management reporting lines are structured; the way in which its budgets are internally allocated; and the character of the individuals who are in charge. Even though none of those things will feature in the Bill, we will want to be reassured on all of them. By itself, a change of structure does not lead to success; the culture and the people within the organisation do that.
	I should be grateful if the Minister, when winding up, could clarify two points about Ofcare. The first is whether Ofcare will have the job of assessing commissioning undertaken by PCTs. The second is whether it will retain the role currently performed by the Healthcare Commission in relation to complaints made against the NHS.
	Culture is also a central issue to the reform of the GMC. In many respects, it is possible to argue that the culture change within the GMC has already taken place under the able leadership of Sir Graeme Catto. The trouble is that, as he has recognised, that change has not been enough to satisfy the public. Despite the fact that lay people now make up 40 per cent of the council, public perceptions of the GMC are of a body that, in the final analysis, looks to protect its own—hence the proposals that are coming before us.
	There are perhaps two main areas of contention in the proposals. The first is the disappearance of the professional majority on the council, which some regard as the death knell of professionally led regulation and standard setting. The second is the change from the criminal to the civil standard of proof in fitness-to-practise cases. Personally, I am unsympathetic to the first complaint, but I am by no means unmoved by the other. The fear is that the change will lead to defensive and unadventurous medicine.
	We are assured that in very serious fitness-to-practise cases the civil standard of proof will amount to "beyond reasonable doubt" under the so-called sliding scale. We are also told that six out of the nine professional regulators already use the civil standard without apparent problem. Yet we know that, in the family courts, child protection cases are judged on the balance of probabilities precisely because unacceptable risks must not be taken with the safety of the child. We will want a lot more detail about how the sliding scale will operate in practice before we can feel relaxed about it, especially as decisions in fitness-to-practise cases will be taken not by the GMC but by a new and completely separate adjudication body.
	The backdrop to all this is the question of how we should define professionalism and, in particular, how we should encourage and foster it. Fostering professionalism is achieved not only by the threat of disciplinary proceedings and corrective action; it is also done by tapping into the sense of pride that doctors have in their own performance and by enabling doctors themselves to recognise where they may be falling short. The Minister may be aware of the Maastricht experiment, under which doctors could look at their own performance on a graph. Their performance was measured against that of their peers but was confidential. It would be interesting to know whether anything similar is being contemplated in this country.
	It is perhaps good to end on a more upbeat note. I mentioned culture change. One culture change too far would have been to go ahead with the Government's proposed amalgamation of the HFEA and the Human Tissue Authority. The arguments against doing so were overwhelming and I am glad that Ministers have agreed with the advice of the Joint Committee on this issue. The Second Reading of the Human Embryology and Fertilisation Bill is due shortly and I do not propose to say much about it now; other noble Lords who are more expert in the subject will in any case deal with its provisions. Two matters are, however, likely to occupy us particularly. The first is the whole issue of embryos containing both human and animal material and the ethical considerations surrounding that idea. The second is the extent to which the regulator should be given discretion in judging which entities may be created for research under licence. We may also be occupied, although I hope that we are not, with issues relating to abortion. On this side of the House, the Bill will be debated on the basis of a free vote. It would be very helpful to hear from the Minister that the same will apply to those on the government side.
	We have an interesting Session ahead of us. For my part, I look forward to giving what help I can to the task that we are privileged to have: scrutinising the legislation before us and, where appropriate, suggesting improvements. I have more than just a feeling that a few such improvements may be forthcoming along the way.

Baroness Barker: My Lords, it is, as ever, a privilege to open this part of the debate on the gracious Speech on behalf of those on these Benches. I, too, congratulate the noble Lord, Lord Darzi, on the eloquence with which he introduced what I imagine are for him some very wide-ranging and new subjects. He did so with great authority.
	These occasions provide a rare opportunity to consider key policy themes, as well as giving your Lordships a chance to probe the Government's wider intentions behind their legislative programme. This year, it is particularly difficult to do so, in part because much of the attention has already been focused on the detail of the substantive issues in the two pieces of legislation mentioned by the noble Earl, Lord Howe—the Human Fertilisation and Embryology Bill to regulate embryology and the Health and Social Care Bill to merge health and social care regulatory bodies—which have already provoked a great deal of detailed debate. One can, however, detect two themes that have run through the commentary on the gracious Speech. The first is trust: trust in the integrity of science and scientific research; trust in professionals, whose responsibility it is to apply that scientific knowledge to the difficult physical and mental conditions in which human beings live their very different lives; the trust which professionals, clinicians, social workers and teachers place in government to provide the resources that enable them to do their jobs; and, above all, the extent to which people and communities trust government to steward public resources to meet emerging demographic needs.
	The second theme is the extent to which professionals have the freedom to pursue what they know to be right for those whom they seek to serve. Those two key issues are difficult to assess in this gracious Speech for two reasons: first, because of the reform of the NHS proposed by the noble Lord, Lord Darzi; and, secondly, because of the future funding of social care. Neither is addressed anywhere in this speech or in this legislative programme. Those two matters are the key backdrop to all that we will discuss over the coming 12 months. Therefore, it is difficult to assess exactly how much the Government can be trusted to deliver high-quality public services.
	Resources are the other issue. The Comprehensive Spending Review for 2007 was the worst settlement for local government for 10 years. Although it is true that there was 1 per cent real growth, most of that will be used to meet PFI liabilities. The projections in CSR07 assume efficiency savings in local government expenditure of £5 billion. In the last spending review, local authorities managed to find savings of £3.5 billion. Local authorities currently spend £7.8 billion on social care, but with a growing number of older people and people born with severe disabilities who will have a lifelong need for high levels of social care, there is a real crisis. The crisis is most evident at local level. For the past four years Sir Derek Wanless has told us that we will not be able to assess the state of the NHS and future demand for services until that issue is satisfactorily addressed.
	I was interested that the noble Earl, Lord Howe, did not mention the White Paper that the Conservative Party published last week, in which the main proposal is to establish an independent health board for the NHS. I am sorry that he did not mention it because that is an interesting idea—although it would not work. The idea that any Government would give £92 billion of public expenditure to a body of people who would be wholly independent is unworkable. Nor would the idea find favour with practitioners or users once they had worked out that although it might be called an independent management board, it would in fact be responsible for the allocation of NHS resources and promotion of patient choice, for involvement in health and the provision of safe, high-quality health services. It would be another layer of performance management.
	We on these Benches have realised that the centralised model of public services is exhausted. Now it is the job of politicians who are committed to finding ways of increasing the quality of public services to find ways of enabling the politicians responsible for the resources, the professionals with the scientific and professional knowledge and the people who use the services to engage in a debate about strategy and the deployment of the resources to meet the emerging needs. My colleagues and I are therefore pursuing the idea of establishing local health boards which would be democratically accountable to local communities and would provide a forum in which social and health care needs could be properly addressed. That is the model in other parts of the world, such as in New Zealand, and the idea has much to commend it. It has proved to be successful in tackling health and social inequalities—politicians' key role in health.
	I shall deal with the health and social care aspects of the gracious Speech and my noble friend Lady Sharp will address those on children. As someone whose maiden speech in this House was on the subject of young people leaving care, delivered in a debate initiated by the noble Earl, Lord Listowel, I am delighted to see the inclusion of a Bill dealing with children in care. I know that many noble Lords, not least the noble Earl, will give the Government a hard time over any legislation that falls short of delivering the means necessary to equip these young people for life well after they have left care. As we are beginning to realise from research, those needs continue throughout their lives.
	The Health and Social Care Bill has long been trailed, ever since the then Health Secretary, John Reid, announced the merger of the Healthcare Commission and CSCI just after CSCI opened its doors. Many of the Bill's provisions were debated in your Lordships' House on 18 April, in a very good and crisply focused debate on the document, Good Doctors, Safer Patients. We on these Benches will support measures to improve professional standards and increase public confidence in the medical profession. It would be regrettable, however, if Parliament were to undermine professional self-regulation, which in all but exceptional circumstances is a powerful force exerting discipline on highly skilled professionals and goes far beyond that made possible by formal lay involvement.
	There has been much discussion about the Government's proposal to change the standard of proof for medical practitioners from the civil standard of "on the balance of probability" to the criminal standard of "beyond reasonable doubt". We on these Benches will question whether the Government's proposal will deliver better outcomes for patients and staff than the current practice, under the case law in McAlister v GMC, where in practice both standards of proof are used and the question of which standard of proof is given most force will depend on the severity of the issue at hand. We will probe the Government hard on this issue.
	I turn to the merger of CSCI and the Healthcare Commission. As Ministers will be aware, there is widespread concern that this body will be medically dominated and that social care will be the poor relation. Like the noble Earl, Lord Howe, I want Ofcare to be well resourced and to do a good job. In particular, I hope that the new body will be able to clear up one anomaly—that although independent-sector social care providers are subject to regulation, they are not subject to the Human Rights Act. This loophole affects many in residential care and the House should pay due attention to that.
	It is self-evident that the system of pre-legislative scrutiny, which we welcomed when it was introduced, has proven its worth in the field of human fertilisation and embryology. I am glad that the Government accepted almost all the recommendations of the Joint Scrutiny Committee. However, one topic remains to be further explored in detail. Individuals have an overwhelming right to know their identity, including their genetic identity. Although this may be a very small part of one's overall social identity, it is important. We will therefore need to spend considerable time on the issue of how those conceived by means of donors can find out who their genetic parents are. We should not stray from the absolute right of donor-conceived children to know their genetic identity, should they choose to find it.
	It is ironic that much of the commentary on the gracious Speech has focused on abortion, an issue that was not mentioned in the gracious Speech and is not actually part of the legislation. The noble Earl, Lord Howe, indicated that there will be a free vote on this issue for those on the Conservative Benches. There will be for us, too. This is one of the most contentious issues and everyone comes to it with their own predisposition. Some are implacably opposed to any measure that would change the law, and others take the completely contrary view. I suspect that many noble Lords, like many members of the public, do not approach the issue from a position that is hard and fast but wish us do something important—once every generation, to consider the changes in science and technology, and to decide the ethical and moral framework within which these developments are evaluated. I commend to noble Lords the report of the House of Commons Science and Technology Select Committee, which examines only the scientific aspects. Noble Lords, particularly those concerned about the crucial issue of foetal viability, will find evidence in the report of which they should take note.
	It is also ironic that today we will not be discussing the most important health measure in the Queen's Speech—the Climate Change Bill, the one measure with the greatest potential effect on the future health and well-being of children in the United Kingdom and around the world. However, welcome though the Bill is, we believe that it does not go far enough. It should include all greenhouse gases and matters such as shipping and aviation. If we as politicians really are to earn the trust of the public, the public will have to know that we are worthy stewards of the planet's natural resources.

Baroness Finlay of Llandaff: My Lords, perhaps I may start by congratulating the Government. I have had the privilege to be on the End of Life Care Strategy Advisory Board, and as noble Lords know, I introduced a Bill on palliative care in the last Session which completed its passage through this House. The thrust of my Bill was to ensure that each strategic health authority and trust would have to develop a palliative care strategy and report on it to the Secretary of State. So I am delighted that the Government have already called on SHAs to do exactly that, even though the overall national strategy itself will not be published until the summer. I am also delighted that the Minister has already done so much himself to foster such important initiatives. But if the Government do not maintain universal improvements in palliative care as a central theme, I assure the House that I will be seeking support again.
	What was missing from the gracious Speech? Every year, around 200,000 deaths are reported to coroners, but where is the long-awaited coroners Bill? The Government have dropped it for the second year running. There is a need for a chief coroner, a need for full-time medical examiners, and for powers to conduct more effective investigations to detect unnatural deaths. I seek an assurance that the Government will use this time to work with the Royal College of Pathologists and others who want such a Bill in order to iron out the more contentious aspects so that, when it is eventually brought before Parliament, the long-overdue coroners Bill will have a smooth passage.
	The gracious Speech made much of the need to harness the workforce. Many want to work part time and thus combine work and family life. The Chief Medical Officer rightly identified the changes in the medical workforce in the chapter entitled "Opportunity Blocks" of his 2006 report. In medicine, around two-thirds of graduates are now women, yet the hurdles remain to block careers. Although within medicine and surgery work already undertaken has identified problems and possible solutions across all the different specialties, that intelligence needs to be brought together to change management attitudes and to make "part time work" work. It will solve many problems.
	Doctors are needed at weekends and at all times of the day and night, so why not harness weekend and evening working? The Medical Women's Federation has been calling for each NHS trust to have a bank of registered vetted babysitters who can be called on in an emergency if other childcare arrangements fail, so that the parent can go to work secure in the knowledge that the emergency arrangements are safe. The Government can make much-needed change in work patterns and careers happen fast, so I hope that they will not forget all the lessons Sir John Tooke brought so eloquently to our attention in his report on modernising medical careers. Yet while the working arrangements may keep women in the mainstream of medicine for the benefit of patients, I fear that the proposed changes in regulation of the medical profession may benefit no one. The most damaging proposal is the move from the criminal to the civil burden of proof in cases against doctors.
	At this juncture, I simply remind your Lordships that the Bristol inquiry concluded:
	"The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved. The system of clinical negligence is part of this culture of blame. It should be abolished".
	The report on Bristol went on to say:
	"For a culture of openness to succeed, those who work in the NHS must be confident that they will be supported by the organisation at all levels. Openness must be valued and rewarded. Otherwise, healthcare professionals will understandably be reluctant to embrace it".
	Yet the Government's proposals go towards blame and stigmatisation, which will drive the professionals into defensive practice and encourage cover-up and we will have abandoned the lessons that we so sadly had to learn from Bristol.
	The Human Fertilisation and Embryology Bill introduced today will be debated soon. I am deeply disappointed that, with all the talk of creating embryos, there are no proposals to deal with the tidal wave of unwanted pregnancies and teenage pregnancies. Why are there no proposals to make oral contraception available over the counter? The safety data support such a move, so why does it not feature here? This is a topic that I will address more fully at Second Reading.
	Another glaring omission is any action on our poor record on intrapartum deaths, which are often unexplained and no longer fully investigated. Our record is considerably worse than that of North America and Australasia.
	The Government seem have ignored large tranches of their own Chief Medical Officer's report. His excellent report this year highlighted the appalling shortage of donor organs, yet we see no Bill here on organ donation. Last year, more than 3,000 patients had their lives saved or improved by an organ transplant. Of these, 2,385 received an organ from a deceased donor and, in addition, 2,402 patients had their sight restored through cornea transplant. There are currently 7,474 people waiting for organ transplant: 74 of those are awaiting a heart transplant, while a staggering 6,587 are awaiting a kidney. The average waiting time for a kidney transplant is now two years.
	We need a new system of organ donation, one which will allow for supply to meet the need or the demand. I urge the Government to look carefully at an "opt-out", or presumed consent, system for renal donation after death. Kidney donation has dramatic results; it can transform the recipient's life. Seventy per cent of the public say that they would be willing to donate, but only 20 per cent have registered on the NHS organ donation register to donate their organs after death. But despite 14.1 million people being registered, 459 patients died last year while awaiting their transplant. That is more than one a day, waiting on the list and dying before they get there.
	Organ shortages lead to poor tissue matches and greater risk of transplant failure, and so it gets worse and worse. Those who are desperate will sometimes turn to the terrible trade of organ trafficking. This trades on poverty and despair, often in the poorest parts of the world. It is tragic, but it will continue if the Government do not grasp the nettle of deceased donors.
	Finally, I turn to a different type of trafficking referred to in the gracious Speech—that of drugs. Have the Government heeded the debate that we had recently in this House? I simply reiterate the call for an agricultural policy that works with Afghan poppy farmers so that we buy up the raw opium and encourage other crops. Surely we must have a policy that allows us to grow poppies, not terrorists.

The Lord Bishop of Leicester: My Lords, many of us on this Bench add our congratulations to the Government on their plans for legislation as outlined in the gracious Speech. There is much we welcome here, and we look forward to making our contribution to the debates on the many Bills that will come before your Lordships' House. However, there is no greater duty placed on a Government than that of their care for their most vulnerable in society. It is on that issue that I shall focus today, particularly in relation to children and young people, speaking as the chair of the Children's Society.
	I welcome the Government's proposal to radically improve childhood outcomes and life chances for all children, especially for looked-after children. I welcome the implementation of the Government's White Paper, Care Matters, as the reform of the care system proposed in the Children and Young Persons Bill is, as we know, long overdue. The Government's aspiration to reduce the outcome gap between children in care and their peers and to improve the experience of education for children in care is clearly right but, as always, this particular legislation will require close examination and monitoring. That is because, as I am sure this House is aware, for successive generations we have not satisfactorily looked after our children and young people in care. We need to ensure that the many suggestions arising from the debate on the White Paper do indeed find their way into the proposed Bill and that we are able to build a consensus around the reforms needed.
	Policies without people and resources, however, are empty shells and doomed to failure. The new legislation reflects high ideals about what children need, but local authorities—as we have already heard today—are overstretched. We know that council taxes are not going to cover the extra resources required. Professionals involved in making crucial decisions about the welfare of children are boxed in by diminishing budgets and increasing demands on their resources. I wonder how the local authorities are going to find the money to make these proposals work, when the Pre-Budget Report failed to show how we are going to make the painful decisions needed about the redistribution of wealth.
	In that connection, I want to draw attention to the one in three children who are living in poverty or with serious inequalities today. Many of these children are suffering family breakdown and rely on child maintenance. The Child Maintenance Bill is the focus of enormous concern about the crucial role maintenance plays in relieving child poverty but also anger about the inability of the Child Support Agency to create a straightforward and effective way of collecting the maintenance. To many commentators the Bill seems to be just a repackaging of old models, rather than containing any radical rethinking of how best to spend government money in this area and encouraging parents to be generous towards their children according to their own means.
	There are two specific aspects in this area where I encourage the Government to be bolder. I hope the new legislation will include a right to advocacy for children with disabilities. As the Children's Commissioner for England stated in his response to the Care Matters Green Paper consultation,
	"Advocacy offers crucial protection where children face particularly complex circumstances, are in contact with many different services, or have communication difficulties".
	There are some 13,300 children and young people with disabilities placed away from home in England and they need a statutory right to independent advocacy, which is about helping them get their views heard and helping them take their proper part in the decisions that affect their lives. This is what gives them dignity, respect and independence, which they are so often unintentionally denied, and it can provide a source of protection by ensuring that their voices are heard within what is otherwise experienced by them as a closed system.
	Yet, despite government guidance which says that advocacy providers should ensure that their services are accessible to disabled children, new research has shown that that is not the case. For example, over two-fifths of those surveyed said that they could not provide advocacy for children who did not communicate verbally and over one-third of the services could not provide advocacy for autistic children. Of course, parents can be the children's first and best advocates, but children need formally appointed advocates when the problem is about the child's parent or primary carer or when the child does not want to share their concerns with their parent or simply chooses the independence of having their own advocate.
	Another vulnerable group is children and young people who enter this country unaccompanied as asylum seekers. We need the Government to move towards a guardianship scheme for children such as these. Each year, some 3,000 children come to the United Kingdom to seek asylum and they can become virtually invisible when they enter the highly complex asylum process, putting them at risk of exploitation and many other forms of harm. Many have experienced abuse, loss or trauma and need support to help them to be able to talk about what has happened to them before they can make an asylum claim. Local authorities work hard to offer support to these children but their work needs strengthening, supporting and resourcing. The proposed legislation focusing on the care of children and young people provides us with an opportunity to ensure that unaccompanied children seeking asylum are provided with the guardianship that they need to navigate the care, support and asylum processes, as might a parent for a child within a family. Such schemes operate successfully in other countries, where they ensure that the child's best interests are safeguarded in all legal and other proceedings affecting them. Surely this is the least that we should be doing for this most vulnerable section of our children.
	I turn briefly to comment on one other area of the gracious Speech under debate today. I very much regret that the right reverend Prelate the Bishop of St Albans is unable to be in the House today to speak on the Human Fertilisation and Embryology Bill, as he made a significant contribution to the work of the Joint Committee which scrutinised the draft Bill. I know that he would have welcomed the Government's decision not to create a new regulatory body combining the functions of the Human Fertilisation and Embryology Authority with those of the Human Tissue Authority. No single body could give adequate scrutiny to such a wide range of important questions, but, as the Church of England's response to the Joint Committee outlined, we remain deeply cautious about the creation of cell nuclear replacement embryos—that is, cloned embryos—and especially about the creation of human/animal hybrids. We will continue to press for very tight controls on embryo experiments and for constant review of the licensing of research into hybrids to ensure that the claimed therapeutic benefits are the only rationale for continuing research programmes.
	The start of any new Session of Parliament brings a sense of hope and expectation—perhaps especially one with a new Prime Minister at the helm. I am conscious of the demands that such hope and expectation will place on your Lordships' House and the desire of the Government to deliver on their commitments, but the care of the vulnerable and those without a voice is the standard by which any civilised and just society must be judged. I hope that in this Session we will have the resolve to defend those most in need and place the vulnerable, and especially the needs of children and young people, at the heart of our concerns.

Lord Warner: My Lords, I apologise to my noble friend Lord Darzi for missing the first part of his speech, for transport reasons that were totally beyond my control. It is a pleasure to participate in the debate secure in the knowledge that I will not have to wind it up and think of something sensible to say in response to the diverse contributions that your Lordships will no doubt make. I readily sympathise with the position of my noble friend the Minister, so I shall try not to add to his burdens in that respect.
	As someone who has a long-standing interest in social policy and a commitment to the interests of children and young people, I thought that the gracious Speech and its legislative programme were a good blend of the visionary and the practical. It is an ambitious programme, which extends education and training to 18 year-olds, provides mechanisms for increasing social and affordable housing, improves services for vulnerable children, especially those in care—I shall speak about them in a moment—strengthens workplace pensions, uses unclaimed money in bank accounts to improve youth facilities and helps to improve the balance between work and family life. Those on the opposition Benches in another place who suggested that the programme lacked vision were really saying that they do not like the vision of a Government who are concerned with social justice, fairness and opportunity.
	I welcome particularly the measures to improve services and, I hope, outcomes for children in and leaving care. For far too long, and under successive Governments, their life chances have been poor when compared with those of their contemporaries outside care—I know that from my six years as a director of social services. I hope that the Government will commit the resources necessary to ensure much more stability in the placements of young people and the stability of the key workers and mentors who support them during their time in care. Those young people, who never chose to be in care, hunger for greater stability and continuity in the significant adults who work with them.
	We know from the expansion of youth facilities how much those services and activities can contribute to reducing crime and anti-social behaviour among young people. I saw that during my time as chair of the Youth Justice Board, when we used the money provided by this Government to expand preventive programmes. I hope that measures in this area will enable us to take those preventive programmes much further.
	There is one area of the legislative programme, affecting another group of children, where I hope—although I have fairly low expectations—that it is not too late for the Government to think again. This group consists of the as yet unborn children who will be affected by a proposed change in the Human Fertilisation and Embryology Bill. That the Bill retains the duty in the 1990 Act to take account of the welfare of children in providing fertility treatment is welcome. Less welcome is that the Government are, it is believed, proposing to remove the words,
	"including a child's need for a father",
	from the concept of children's welfare in the 1990 Act. I understand the pressure that the Government have been under on this issue; I know the power of some of the lobbies that have argued on it. However, children are not accessories to adults' preferences. I hope that we in this House will think again about retaining the words of the 1990 Act on a child's need for a father.
	On a happier note, I turn to the Health and Social Care Bill. I should acknowledge that I was heavily involved in the Bill as a Minister, so it will come as no surprise that I fully support the Government's approach in it. On the changes to the healthcare professional regulatory bodies, there are already rumblings from BMA House. When the Bill is in this House, I have no doubt that your Lordships will be briefed to the effect that civilisation as we know it will end if there is a change to the civil standard of proof in professional disciplinary cases. I urge noble Lords to use their well honed powers of scepticism and capacity for detecting the whiff of self-interest in considering these aspects of the Bill. The Government deserve our support on this issue in the interests of patients, as the General Medical Council well recognises.
	On the other main measure, a new integrated system of health and adult social care regulation, we shall no doubt have many discussions in this House. A lot of the devil will be in the detail. The noble Earl, Lord Howe, and I are veterans of earlier discussions on some of these issues in the 2003 Act, and I am sure that we shall dust off our campaign medals and volumes of Hansard to return to some of those issues during debates on this legislation.
	All that I should like to do today is to offer two pieces of advice to my noble friend the Minister to pass on to his colleagues in Richmond House. First, a new regulatory system in this area must be totally even-handed and operate on a level playing field between service providers, whether from the public, private or third sectors or from social enterprises. I include in that the important point made by the noble Baroness, Lady Barker, about the application of the Human Rights Act provisions to all providers of public services, including health services. That approach is critical to the promotion of choice and competition, as the Government recognised in their original consultation document and recently published response to that consultation. If we are to have the personalised healthcare system that the Prime Minister rightly wants, choice and competition with a mixed economy of providers, in an open and fairly regulated market, are critical to success. I believed that as a Minister and shall continue to do so as we take the Bill through this House. We need to make market entry and exit as equivalent as possible for all providers of NHS services.
	The second key issue is the coverage of the registration of care providers, to be included in the new regulatory system. The Government are rightly consulting further on the issue. I remind them, as they consider this further consultation, to remember the January 2006 White Paper, Our Health, Our Care, Our Say: A New Direction for Community Services. This demonstrated that the traditional boundaries between primary care, community services and secondary care were being blurred rapidly with advances in medical technology and changes in patients' preferences. That point is well understood and has been well argued by my noble friend Lord Darzi in the work that he has done in reviewing the NHS in London and elsewhere. Any registration system that excludes significant elements of primary care and community services will not produce a fair regulatory system and will ossify the development of more patient-responsive services. Whatever the pressures from vested interests to be excluded from the regulatory system in this area, I hope that the Government will see them for what they are and ignore them.
	I have resisted the temptation in this speech to respond to the criticisms that the noble Earl, Lord Howe, made of the Government's stewardship of the NHS, including no doubt my part in that stewardship as a Minister. He will be surprised to hear me say that I believe that over the 10 years of this Government we have made some mistakes—but we have also tried to correct them. However, those mistakes pale into insignificance compared with the failures by the party on the Benches opposite to invest in the NHS in the two decades before we took over responsibility; that party left the NHS on its knees and with a deficit that in percentage terms was higher than has ever occurred under this Government.
	In conclusion, I congratulate the Government on a visionary and practical gracious Speech and legislative programme, which continues public service reform in the interests of fairness, opportunity and service-user responsiveness, and on their continuing good stewardship of the NHS.

Lord Fowler: My Lords, I was going to congratulate the noble Lord, Lord Warner, on a speech free from the shackles of government, but as, judging from his last remarks, he seems a bit reluctant to leave those shackles, I shall modify my congratulations. The noble Lord was a senior civil servant in the DHSS when I became Secretary of State. I do not take it personally but I note that he left immediately I arrived.
	I congratulate my noble friend Lord Howe on his speech. I was concerned only by his reference to the Maastricht experiment. I do not know what the Maastricht experiment is, but my experience as Conservative Party chairman leads me to the conclusion that we should strongly avoid anything to do with Maastricht.
	It sometimes needs an outside intervention to clear the mind on the National Health Service. Over the last weeks, two prominent American politicians—both, as it happens, fighting for the Republican nomination for president—have gone out of their way to criticise the National Health Service as well as many other things European. At the end of October, Mitt Romney singled out the British National Health Service for criticism and warned America of the danger of becoming a second-tier nation like Britain and other European countries. Then Rudy Giuliani attacked the National Health Service even more specifically and claimed—as it happens, quite wrongly—that the survival rate from prostate cancer in the United Kingdom is only 44 per cent under what he termed "socialised medicine". In actual fact, the figure is 75 per cent, but that has not prevented him from launching a radio advertising campaign complaining of European-style socialism.
	For six years I was Health Secretary in Margaret Thatcher's Cabinet. As we developed the National Health Service—I hope that the noble Lord takes note of that phrase—it had not occurred to me that we were involved in some vast left-wing project. It was not a criticism normally made of Margaret Thatcher, any more than it was of Churchill or Harold Macmillan, who also followed the same policy. The sensible attitude to take, and the point to remember, is that the National Health Service has been developed by Governments of both parties and will continue to be so. Frankly, I do not entirely comprehend the language of the two contenders campaigning against the nations of Europe when we assume that their aim—if ever they were to be elected president—is to have good relations with those European nations. I should not have thought that the United States is so rich in overseas friends that it needs to kick those who are already friends, but I leave that to one side.
	The principle of the National Health Service and its whole basis is that no one should be prevented by a lack of income from accessing good healthcare. That is an important principle and one worth fighting for. I am delighted that the leader of my party, David Cameron, has emphasised his commitment to it. Does that mean that the National Health Service is perfect? Of course it does not. Too often extra resources have not resulted in improved services. Back in the 1980s, I introduced not administrators but general managers. That has led to much improvement. If I was to go one step further, I would separate the management of the health service from the health department. The latter contains much professional expertise but not necessarily vast management experience.
	There are undoubtedly areas where the health service can be improved. Examples were given by the noble Baroness, Lady Finlay, who leaves the Chamber immediately that I mention her name. That practice seems to be catching, but the noble Baroness may go; I shall not mention her again. The National Health Service is failing in the area of public health, particularly HIV/AIDS and sexual health generally. I doubt whether that would come high on the list of Messrs Giuliani and Romney. Almost exactly five years ago in a debate in this House, I warned that:
	"It is estimated that there are currently 30,000 to 35,000 people living with HIV. New reports of HIV infection last year approached 5,000. That is the highest ever annual total and represents the fourth year in succession that there has been an increase".—[Official Report, 19/11/02; col. 305.]
	Today that position has deteriorated further. New diagnoses are now 7,500 a year—a figure that has trebled in the last 10 years. The number living with HIV is now between 70,000 and 75,000, not 30,000 and 35,000, and there is unmistakeable evidence that young people in particular are ignoring safe sex messages.
	The Royal College of Nursing rightly points out that HIV is not just a sexual health issue but a chronic condition, as people with HIV now live into their 50s and 60s, producing a need for specialist nurses working in HIV care, while all the time many of those with HIV suffer prejudice. Recently I was looking at HIV in India, where there were certainly examples of prejudice. I regret to say that there are examples of it in this country, too. I am a trustee of the Terrence Higgins Trust and only this week a very reputable charity wanted to know what it should say in warning its clients that the furniture donated to it had belonged to someone with HIV. This is 25 years into the epidemic in a highly educated society. The prejudice is born of ignorance, which in turn comes back to a lack of public information and discussion.
	Of course, HIV/AIDS is not the only problem. The figures for sexual health generally provide no greater comfort. The latest figures show that new instances of chlamydia have doubled over the last decade. In 1998 the figure was 48,000; today it is something like 110,000. If you take another sexually transmitted disease, syphilis, you find that whereas in 1998 it had almost disappeared, today there are almost 3,000 cases a year. This is a great challenge to this country. Why do we not take the issue more seriously? Perhaps we take the view that, as the issue is more serious in some overseas countries, such as those in Africa, we can be relaxed about it. I do not think that that is right. If we have pretensions to give aid and help in those areas, we should set an example.
	The great irony is that we took more urgent action back at the time of the First World War when confronted with the scourge of venereal disease. We set up a royal commission, opened clinics around the country and promised immediate walk-in and anonymous treatment. Today, the clinics are overcrowded and too often rundown, and delays in treatment are all too common because appointments have to be booked. It is not a good story. Almost 100 years ago our predecessors showed more determination to tackle the issues effectively.
	I do not claim for a moment that all the issues can be solved by government. The churches, particularly the Roman Catholic Church, can do more. It is a tragic irony that the Catholic Church, with all its influence and power to do so much through its aid societies—it does a vast amount through them—to care for the victims of HIV/AIDS, does so little to prevent it. Its attitude to condoms as a disease prevention measure is a case in point. So much suffering and death could have been prevented by taking a more sensible attitude in that area.
	Government cannot do everything but they can do much more to tackle the crisis—and it is a crisis—that we face today. There are three central failures of policy. The first failure is in public education. The efforts to get over general messages of information and advice in this area have been woefully inadequate. The public will listen to authoritative advice given by professionals such as the Chief Medical Officer in the Department of Health, but that advice has not been given on a national scale in a convincing and persuasive way. It never occurred to me when I ran my campaign in 1986 that the Government would, in a truly national sense, go off the air for the next 20 years.
	The second failure is in education. Young people are often still not receiving good-quality sex and relationship education. We raised that point with the Minister in a debate some months ago. Properly taught, it can lead to young people starting sexual activity later, having fewer partners and being much more likely to take precautions against sexually transmitted infection.
	The third and crucial failure is funding, to which my noble friend on the Front Bench referred. Not only is the area generally underfunded, but even when an effort is made to provide resources they all too often do not reach the service providers. The Government made a much publicised announcement about how they were providing £300 million to be targeted on sexual health. Press releases were written and ministerial Statements were made, but the only trouble was that a large proportion of that £300 million did not reach the sexual health services or result in major public education campaigns. The decision was left to the primary care trusts, many of which used the money to pay off budget deficits or for other purposes. Many trusts do not have HIV or sexual disease as a priority. It is not a cause that has loud public support and the trusts reflect that. I am in favour of devolution, but in public health, particularly sexual health, the case for ring-fencing budgets seems to me to be overwhelming. Public health is a national responsibility; there are no boundaries in infection and it should be dealt with in that way.
	This is not a popular area of policy-making; we all know and recognise that. Those who enter it are liable to be attacked from the right and ridiculed from the left. Nevertheless, it is a vital area. Disease is disease and in a truly national health service it should be tackled with commitment and energy. Most of all, this area needs political leadership. Frankly, that leadership has been lacking for a number of years.

Lord Low of Dalston: My Lords, in government it must often seem that you cannot win: if you give advance notice of your legislative programme in the interests of greater transparency, when it comes to the Queen's Speech you are told that it contains nothing new. The gracious Speech is said to be long on aspiration but short on vision. It is our job to hold the Government to account, but in an age when the business of politics is increasingly debased by partisan agendas, the 24/7 news culture and the corrosive canker of cynicism, it seems to me that we ought to be prepared to give credit where credit is due.
	A programme designed to meet people's aspirations—for better education, housing, healthcare and children's services, with a commitment to raising educational standards along with the school leaving age and addressing the important skills agenda of the Leitch report; which envisages the building of 3 million new homes in the next 10 years, the largest house-building programme since the 1950s, which is long overdue; a healthcare system organised around the needs of the patient; all children having the best possible start in life and improved services for vulnerable children and young people, including those in care; a better balance between work and family life; which is committed to tackling climate change in a manner which suggests that it means business; and to tackling congestion and improving public transport; not to mention the even larger agenda of reducing global poverty with renewed efforts to achieve the millennium development goals—such a programme hardly fails on the score of vision.
	It is on the score of delivery that it seems to me that Governments—all Governments—are vulnerable, and increasingly vulnerable, in a society beset by a crisis of authority, where the imperative of consultation means that all decisions are contested and where the traditional levers of influence flop limp in Ministers' hands.
	I was intrigued by the noble Lord, Lord Anderson, saying in yesterday's debate that the problem lay mainly in the external arena and that domestically delivery could normally be guaranteed—would that it were so! Nowhere is the gap between rhetoric—no, let us be fair—intention and performance more stark than in the arena of social care, which is truly the Cinderella among the subjects we are debating today. Expenditure on personal social services has increased substantially in recent years, by 10 per cent in real terms between 2003-04 and 2005-06. That is something for which the Government deserve real credit, but it is still not enough, and growth in spending on social care is being dwarfed by the growing needs of our ageing population.
	Despite the Government's best efforts, provision is falling further and further behind need, and the system is slipping deeper and deeper into crisis. In March 2006, the Local Government Association reported that seven out of 10 people receive social care only if their needs are substantial or critical, and 80 per cent of councils plan to tighten their criteria still further. That has forced many disabled and elderly people back on to their own resources, leaving some to rely on family or friends for essentials and others simply to go without. The Government's answer in the Health and Social Care Bill is stronger regulation. That may help to drive up standards, but it is also a question of resources. The above-inflation increase for the Department of Health in the recent Comprehensive Spending Review should not be allowed to conceal the fact that, with growth in the funding for local authorities standing at just 1 per cent above inflation over the next three years, much of which is already accounted for, social care services are promised relatively little. If the Government can be asked to reconsider the adequacy of their spending on defence, should they not also reconsider whether their spending on the needs of the most vulnerable in our society is adequate and whether fair access to care services can continue to be sustainable at this level of funding?
	We must never lose sight of the basic purpose of social care: to enable people to live independently. That is why I have been so dismayed by the bureaucracy of the ordinary residence rules, which stop people moving around the country to new jobs, educational and other life opportunities. I hope that some progress can be made on these issues during this Session. I hope, too, that the Government will be prepared to give a fair wind to the Bill introduced yesterday by the noble Lord, Lord Ashley, to develop a range of services that would enable disabled people to have true independence; either that or bring forward some proposals of their own, perhaps based on the report of the noble Baroness, Lady Campbell, which is currently being considered. That was the object of the Cabinet Office's Improving the Life Chances of Disabled People report, though I would urge the Government not to be beguiled by prescriptions which are too monolithic. There are those who feel, for example, that individualised budgets do not suit everyone, and that the report takes insufficient account of the needs of elderly people—the majority of disabled people—and those with severe, multiple, complex and learning difficulties.
	The purpose of the Employment Simplification Bill is to,
	"simplify, clarify and build a stronger enforcement regime for key aspects of employment law".
	One aspect that I am particularly interested in clarifying and strengthening relates to retaining newly disabled people in work. As part of the Government's welfare to work reforms, I believe that much greater priority must be given to supporting disabled people in work who are at risk of leaving their employment for a reason related to their disability. Catching those people who are likely to leave work for disability-related reasons will, without doubt, bring greater savings for the Government than engaging with the same people once they have left work and claimed incapacity benefit.
	The Government gave a specific commitment in the Warwick agreement to introduce in this Parliament greater support for people who become disabled while in work. As set out in the National Policy Forum report Britain is Working of September 2004, the commitment is to,
	"taking action to ensure that employers fulfil the requirement already on them to make reasonable adjustments for disabled workers including where appropriate granting leave in respect of their disability".
	This policy has gained considerable support in another place as rehabilitation leave. It has been promoted for more than a decade by my organisation, RNIB, but it should now be seen as an idea whose time has come. People who become disabled while in work, or who experience a change in an existing impairment or health condition, would be able to have some time away from work to undertake rehabilitation and retraining to return to their previous role, or if that is not possible, an alternative appropriate position, and so avoid going onto incapacity-for-work benefits.
	I cannot conclude without commenting on the omission from the gracious Speech of a single equality Bill. The Government published a Green Paper in the summer that was intended to prefigure a single equality Bill, but it was the subject of considerable criticism, particularly for the impact the proposals would have had on the disability equality duty. Many felt that the Green Paper lacked, among many other things, vision and failed adequately to address the role of the private sector in promoting equality. It is therefore gratifying to learn that the proposals are being reconsidered.
	However, the Secretary of State's announcement that there will be a Bill in next year's Queen's Speech, but with very limited further consultation or scrutiny, has caused widespread concern. On 25 October she said in another place that,
	"it might not be possible to publish the whole Bill in draft, but we would seek to publish some draft clauses".—[Official Report, Commons, 25/10/07; col. 425.]
	This is not really good enough. On a matter as complex and technical as this, there needs to be further consultation and there is a strong case for a draft Bill to be published in order that pre-legislative scrutiny may take place. Your Lordships will remember that such an approach was adopted for the draft Disability Discrimination Bill, which led to the 2005 Act, and that this was widely welcomed and generally considered to have had a beneficial effect in helping to build consensus.

Baroness Pitkeathley: My Lords, I have worked in the fields of health and social care all my professional life and to declare all my interests would take more time than could reasonably be permitted. I will declare just two. I am chair of CAFCASS—the Children and Family Court Advisory and Support Service—which deals with children and families when they are at their most vulnerable, and I am vice-president of Carers UK, which supports and campaigns for that other most vulnerable group, the 6 million people who provide the majority of health and social care to their families and friends.
	The first thing I want to do, as well as congratulating my noble friend on his opening speech, is to celebrate the title of this debate—that the words "social affairs" are included in it at all. It is perhaps a sign that social care, for so long the poor relation in care matters and always swamped and often overlooked by what are often seen as more glamorous or dramatic issues about saving life or life crises, is recognised at last—or at least becoming more recognised. Social care is much more often about things that are singularly undramatic and most certainly not glamorous.
	I am delighted with the progress that we have made towards more recognition of social care, social work and, indeed, social workers under this Government. We have a Minister for Social Care for the first time and we have a General Social Care Council, of which I had the honour to be the first chair, and which has done so much to raise the status and quality of the dedicated professionals who work in this field. It is a field, let us never forget, which has great difficulty in recruiting staff, not only because of inadequate levels of reward, but because of the extraordinarily stressful nature of working with clients, families and individuals who are most needy and often most hard to help. It is remarkable how easy it is, even for those of us who have spent our lives on the front line, to forget how difficult social work is.
	In this regard, the Commission for Social Care Inspection has been of the utmost importance in championing social care, highlighting successes and failings and providing a strategic lead for the whole sector. The Health and Social Care Bill announced in the gracious Speech will contain provisions to create what I understand will be called the Care Quality Commission—to replace the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. It will require all providers of health and social care to be registered and a consistent approach to regulation and inspection will no doubt bring benefits to patients and to service users. But we must ensure that the expertise built up by CSCI and shown to such advantage in reports such as The State of Social Care in England, published in January this year, is not lost.
	In addition, CSCI has a fine record in making the views of users and carers not just known but central to its functioning. We must ensure that this continues with the new body. It will have a smaller budget, but this is one area where we must not cut corners. We must remain concerned that the institutional attention of the new body does not become entirely focused on healthcare at the expense of social care and that resources are balanced accordingly. For example, there are concerns regarding the fresh duties for the Care Quality Commission, such as the current focus on the cleanliness of hospitals—as a survivor of a severe case of MRSA, I am all in favour of cleanliness in hospitals. But we must ensure that that does not cause already tight resources to move from social care to health. I hope that the Minister can provide some assurance on that in his reply.
	One of CSCI's key functions is that of providing impartial and objective information to potential users of social care services and their families, not least because one third of such people already fund their own care. This role must be continued and, ideally, expanded. It must link effectively with the national helpline for carers that the Government are setting up to provide consistent information to families in need of care services.
	The CQC must support social care services in focusing more on supporting carers in employment. Currently, the 4 million working-age carers are being failed by the system. Evidence from Carers UK's recent employment carers and services research carried out by the University of Leeds shows that more than 40 per cent of those caring full time and not in work say they cannot return to employment because of the lack of services available to support them. Current systems do not support carers at key stages of their lives. They must have reasonable expectations to a life beyond their caring role, as enshrined in the very welcome Carers (Equal Opportunities) Act 2004, but we must help them to fulfil those expectations.
	I wish to mention another Bill that is not strictly the subject of this debate, but carers will very much welcome in the Pensions Bill the creation of a new scheme of low-cost personal accounts that will give them some advantage. We need to make sure that personal accounts are sufficiently flexible for those moving in and out of work, as carers often do.
	There is also a continued need for a stronger focus on carers within the NHS. The NHS will benefit from a 4 per cent increase in its funding, as announced in the CSR. A great many of the reforms are predicated on the basis of people caring for people at home. Yet carers are often ignored and invisible to the NHS. It is vital that we ensure that carers are a priority for spending from the NHS budget, as well as local authority budgets, and that they are treated as partners in care.
	In this context, I want to mention the National Voices initiative—a new collaboration of which I am chair, succeeding the noble Baroness, Lady Morgan of Drefelin—which aims to bring the views of patients, carers and service users directly into the heart of health and social services, attempting to bridge the gap between the rhetoric and reality of user-led policy making. We have been delighted with the support given for this initiative by Department of Health Ministers and have every confidence that National Voices will soon be established as a true partner in the development of policy.
	Other key issues are to be welcomed in the Government's plans—in particular the Green Paper that we are promised on the future of social care funding, which signals a major reform of the current system. The CSR statement made it clear that the Government believe that there are real opportunities for reform within a system that shares the cost between the individual and the state and that provides both universal and progressive elements. A sustainable funding settlement is essential because, while the announced increase in social care spending will help carers and the people for whom they care, it will not, as we have already heard, meet the level of unmet need that currently exists, leaving many families to struggle on as before.
	I understand that my honourable friend in another place is beginning the consultation on the Green Paper immediately. When it is published we hope that at its heart there is a recognition that most care is provided by families and that the formal care system needs to fit around that, rather than the other way around. Of course, the review of the National Carers Strategy is also very welcome. I sincerely welcome the Prime Minister's interest in carers and greater awareness that carers are providing care at a cost to their own health, wealth and employment prospects. We need better recognition of the crucial role that carers play in society, reflecting that the care provided by families massively—I emphasise "massively"—outstrips that provided by formal services. We must also welcome the Standing Commission on Carers, which has been established. It is important that it is given suitable resources and a strong remit to advise across Government.
	The New Deal for Carers, as the revised National Carers Strategy will be known, will be a 10 to 15-year vision. In order to implement and monitor the strategy effectively, it is essential that we have the required statistics. In that regard it is absolutely essential that the carers' questions are retained in the 2011 census. That is an issue on which the All-Party Group on Carers has been active and we must continue to pursue it with the Department of Health, the Treasury and the Office for National Statistics. In fact, all government departments should have an interest in retaining this question if they are to deal accurately with the impact of demographic change. I very much hope that the Minister will be able to give some reassurance on that.
	I said at the beginning that I was glad to see health and social affairs included in the title of our debate today, but I want to conclude by saying how glad I am that education is also included and that the noble Lord, Lord Adonis, is to reply to the debate. CAFCASS is sponsored by the Department for Children, Schools and Families, although it works in close co-operation with the Ministry of Justice because of its work in the court system. However, the fact that our sponsoring department is the DCSF is recognition that the work of CAFCASS is essentially part of the Every Child Matters agenda, and that safeguarding and caring for children at whatever stage of their lives encompasses public and private law issues, education and the provision of social care.
	We should never forget that, for the client, the user and the carer, which agency provides that care is of little interest and almost of no consequence. What is important is the quality of care and the quality of the intervention. To that end statutory agencies, voluntary sector providers and private sector providers must be prepared to work in the closest possible co-operation and partnership, keeping the focus always on the most vulnerable members of society who use the services. Government departments must similarly work in partnership and listen always to the voice of their users. Any legislation and especially some of the legislation we shall be considering in the next few months must keep that at its forefront. Safety and quality is everyone's business and that includes the users and carers.

Lord McColl of Dulwich: My Lords, I, too, congratulate the noble Lord, Lord Darzi of Denham, on his opening speech. We were surgical colleagues together for many years and I enjoyed working with him very much. I think we both find surgery a good deal easier than politics.
	I wish to deal with a practice that leads to a vast amount of ill health. I refer to human trafficking, which is the debasement and violation of one human's rights by another. In March 2007, we remembered and celebrated the great work of William Wilberforce and it is now our duty to eradicate slavery in our society. The facts and figures surrounding trafficking are truly appalling. Save the Children estimates that there are 5,000 child prostitutes in the UK, nearly all of whom have been trafficked. The Home Office recently estimated, in a Written Answer, that as many as 4,000 women victims of trafficking for prostitution are in this country. The International Labour Organisation says that there are approximately 12.3 million people in forced labour, bonded labour, forced child labour, and sexual servitude at any given time. UNICEF believes that two children a minute are being trafficked domestically and internationally. Of course, the nature of this abhorrent crime prevents accurate figures, but when one considers that the generally held estimates in this area could themselves be multiplied by as much as 10, it seems vital that the Government take further action to stop this traffic.
	Eighty-four per cent of those working in brothels are trafficked women. Men who become involved with them may not realise that they are guilty of rape. To remind men of that, it has been suggested that Her Majesty's Government should insist on brothels displaying prominent notices to that effect. That is not all that revolutionary as the Government have already obliged even churches to display "no smoking" signs. There have been many objections to that practice, but I have suggested that one answer would be to have the 10 Commandments listed on the front door of churches, with an additional eleventh commandment, "Thou shalt not fume".
	Stop the Traffik must take action in four key areas: prevention, protection, prosecution and reintegration. We should adhere to the old adage that an ounce of prevention is worth a pound of cure and ensure that the Government's international aid is used effectively to tackle the poverty that enables trafficking to occur. This could prevent stories such as that of a young Czech mother of two who was brought to the UK under the pretence of becoming a waitress. She was brutally raped and beaten almost continuously until she managed to escape through the window of her Peterborough brothel. The subsequent involvement of the Cambridgeshire constabulary enabled her to be returned to her family. It is imperative that our Government help to lower the current US Department of State's estimate that annually about 600,000 to 800,000 people—mostly women and children—are trafficked across national borders and that does not include millions trafficked within their own countries.
	There are many worthy causes worldwide that would benefit greatly from increased aid such as the Thai NGO, Development Education program for Daughters and Communities, which utilizes a mix of strategies to convince parents about the dangers of the illegal sex trade. In many successful cases, the decision of the child to continue her education overrides the parent's desire for money. The charity Stop the Traffik is centred nearby at Waterloo. It is a growing global coalition of more than 900 member organisations from more than 50 countries, working together to combat human trafficking and to raise awareness and empower communities. Perhaps the Government would consider giving financial support to that splendid organisation.
	The Joint Committee on Human Rights considers human trafficking to be,
	"one of the most serious human rights issues in the modern world".
	It outlined the varying forms of enslavement: children drugged and forced to fight as soldiers; men bonded or chained in labour in mines and on farms; women enslaved in quarries and households; women and girls trapped in the sex trade; and boys forced to fish in dangerous waters. Once the victims get in to these awful positions, it is crucial that Governments take care to protect them. The UN Protocol to Prevent, Suppress and Punish Trafficking in Persons stresses the importance of protecting the privacy of the victims once they are freed from traffickers, especially during the prosecution of the traffickers. The protocol also calls upon countries to maintain the human rights of the individuals involved by having secure and efficient systems in place to address the physical and emotional needs of the victims. It is essential that the UK is efficient in providing systems to protect the victims of traffickers if we want to stop these horrific crimes. Some of the children trafficked are as young as five and are brought secretly into Britain to work as domestic servants or in cannabis factories or for sexual exploitation or under-age marriage. According to the UNICEF report, Rights here, rights now,
	"Even if trafficked children are identified, their care and protection is inconsistent, ad hoc and, in some regions, completely absent".
	To help plug the gaps in the system, UNICEF wants reforms, including a professional guardian for each trafficked child.
	The appalling figures illustrate the need for all countries, including the UK, to maintain efficient and successful systems of prosecution and reintegration. The highly clandestine nature of the crime means that many cases remain unreported. This is further complicated because many victims are fearful of attacks on their family if they are involved in the prosecution of their traffickers. The privacy, dignity and security of the victim are paramount. We cannot allow a flawed system of prosecution or reintegration to cause further harm to these individuals who have already suffered so much.
	The international nature of this crime demands an international response, and it is important that technical co-operation links between countries are maintained and strengthened. Information gained through these relationships would be invaluable for understanding the true extent of human trafficking. Special training could be extended to the areas where trafficking often occurs to enable local law enforcement to halt human trafficking at its source.
	Our work does not finish when the victims return home. The process of reintegration is equally as important as rescue or prosecution. Victims are likely to have psychological scars, to encounter social stigma and may have difficulties in gaining employment, especially if they have been treated by law authorities as criminals, either as prostitutes or illegal migrants. The same poverty that made victims vulnerable to trafficking can also prevent successful reintegration. Many communities do not have the resources to provide training or support for returning victims. There are some positive examples, however, which indicate ways in which international aid could assist victims. In the government reintegration programmes in the Philippines, therapy sessions to overcome fear, shame and self-blame are provided in conjunction with programmes which give information on options available to victims for work, continuing education and vocational training. There are also NGO grants of financial and technical assistance for those interested in starting their own small businesses.
	As noble Lords may see, there are many areas where UK involvement would be much appreciated and needed. If there is any way that we can prevent trafficking, protect a victim of trafficking, prosecute a trafficker or enable a successful reintroduction to society for victims, it is imperative that we do so. Can Her Majesty's Government confirm that they are really committed to eradicating this horrendous practice? It is crucial to ensure that people are fully informed about the problem. This applies especially to professionals such as the police, social workers, MPs, councillors and many others. We will need all the help we can get to eradicate this horrendous practice.

Lord Ramsbotham: My Lords, I, too, congratulate the noble Lord, Lord Darzi, on the breadth of his opening speech. Like other noble Lords, I look forward to the vigorous debate that he forecast on some of the issues.
	If noble Lords had been sitting in the Gallery of the other place just before 10 o'clock on the night of 20 July 1910, they would have heard the then Home Secretary winding up in the debate on prison estimates. He said:
	"The mood and temper of the public in regard to the treatment of crime and criminals is one of the most unfailing tests of the civilisation of any country".
	The 36 year-old Winston Churchill went on to say that in pursuit of that there must, among other things, be,
	"a desire and eagerness to rehabilitate in the world of industry all those who have paid their dues in the hard coinage of punishment".—[Official Report, Commons, 20/7/10; col. 1354.]
	When I listened to the gracious Speech on Tuesday, I heard Her Majesty refer to the Government's intention to rebalance the criminal justice system in favour of the victim. That is something I have never really been able to get my head around because I did not think that one rebalanced scales; I thought scales were balanced by evidence. I found the best description of what that means in the context of the criminal justice system on the walls of a young offender institution; it was "to prevent the next victim". We prevent the next victim by rehabilitating people so that they do not create victims. There are no more important players in the rehabilitation process than the Department of Health, the Department for Children, Schools and Families and the Department for Innovation, Universities and Skills because the combination of looking at the healthcare and education needs of offenders is crucial to helping them live a useful and law-abiding life.
	I shall not concentrate on healthcare, because I am sure that will be covered by others, but shall turn to education. I do so because in recent years the ministries that I have mentioned have been responsible for the financial affairs of healthcare and education in prisons and are therefore responsible for the outcomes. Noble Lords may think it is the responsibility of the Ministry of Justice, but those departments' contribution to the funding will make all the difference.
	On healthcare, I was particularly glad to hear the noble Lord, Lord Darzi, mention the importance of the development and use of the budgets, to which the noble Earl, Lord Howe, also paid considerable attention. Within those budgets there is one responsibility of primary care trusts that I never hear mentioned. It is the responsibility for providing diversion schemes for mentally disordered people when they enter the criminal justice system. A recent publication by the Sainsbury Centre for Mental Heath referred to diversion and stated:
	"Diversion can ensure that people with mental health problems who offend are treated in the best and most appropriate settings available. It can also help to reduce the rising custodial population and the increasing re-offending rates for those leaving prison, both of which will help to protect the public and save money that would otherwise be spent on reconvictions".
	My plea to the Department of Health is that it should pay much more attention to the provision of these diversionary schemes to enable that to happen because nobody else can do it.
	I turn to the Education and Skills Bill. I was very glad that the noble Lord, Lord Darzi, mentioned the responsibility that the state has for young people in its care and that parents and carers should be able to choose the most appropriate education for them. I would of course include prisons in that because people in prison are also in the care of the state. Therefore, I was disappointed to discover that the brief I received on the Education and Skills Bill via the internet made no mention of offenders of any kind in the provisions for people up to the age of 18 and19. That is disappointing because I hope that in building up the provision, that for people in the care of the state is examined.
	The noble Lord, Lord Darzi, mentioned, quite rightly, the horrendous number of people who have been in care, and the failure particularly in their education which results in them going to prison. If you look at it the other way around, one is continually horrified by the vast numbers in prison who have come from care and who have failed in education and many other things. That matter really must be included in the future.
	I do not think that I am politically correct in one of my major concerns in education, which is based on my first visit, as far as I can remember, to a British Forces comprehensive school in Germany in 1966. This secondary school was achieving amazing results with children who arrived at about the most difficult times for schoolmasters. They arrived in the middle of term from all over the world as their fathers were posted in, and, of course, they left in the middle of term when their fathers were posted elsewhere.
	However, the school was achieving astonishing results. I asked the headmaster why. He said: "It all boils down to the fact that every child has different abilities in different subjects. We assess their ability in each of those subjects and we send them to classes which are appropriate for their ability. We block the day so that the whole school does English, maths, history or whatever. Then the child goes to the class appropriate for their ability and is encouraged upwards according to that ability". I said: "Goodness me, if that is comprehensive education I cannot think of anything better". He said: "Unfortunately, that may be comprehensive education Hohne-style"—which was where the school was—"but it is not comprehensive education in a country where people move on by year and not by ability".
	There is a lot of heavily political discussion about that, which I do not intend to get into it. However, it has always struck me about people in prison who dropped out of school and who mention frustration and boredom that very often it may have been because their ability was not assessed and channelled at the right time. I mention that because, as regards these young people in particular, I hope that in the Education and Skills Bill the Government will not lose sight of the importance of assessment at the very start to find out what the young person has in them—the treasure in their heart to which Winston Churchill referred—whether it is educational or vocational. That can then be harnessed and put to best use. There is only a limited time available, and it would be quite wrong for the state to waste that time.
	What sort of assessment do I mean? I have previously mentioned in the House that I believe that one of the scourges of the 21st century is the inability of people to communicate with each other. They cannot talk; they do not listen; and they have not been engaged in conversation. That leads to an inability to conduct relationships. One of the worst effects of that is that they are unable to establish that very important first relationship with a teacher when they go to school. They do not know how to communicate with them.
	Speech and language therapists should see every child before they start primary school to help them to communicate so that they can engage in the system and get the best out of it. In prisons that is desperately important in order to get prisoners involved in all the activities they are presented with. At the same time—and again this appears in the requirement to look at vocational skills in this Bill, which I am delighted to see—the aptitude test for vocational skills should be related to what people can do, not to what it is felt would be good for them to do, because self-esteem follows achievement and success. They have not had that. It is remarkable when you see what happens when people are suddenly faced with something they can do.
	My final plea is that the role of the arts is not forgotten as an entry point, a trigger or an identification of what somebody can do on which they can build. The arts have always been seen, rightly, as an entry point to education, skills and training. I hope that that will not be forgotten.
	That may seem a long way from the Bill presented to us. When looking through it, I was slightly concerned to see a long list of duties on parents, schools, local government and so on. I remind the House that there is a duty on government to make certain that provision is made. I was interested to see the Association of Colleges asking for a duty on the Government to provide proper independent advice and guidance to young people as well as high quality education and training.
	I am mightily encouraged by the attitude of the Ministry of Justice to its task. In what I have heard, the same goes for the attitude of the two new education ministries. There is a challenging agenda, but I hope on behalf of all young people, including those in custody in the care of the state, that the opportunities will be seized.

Baroness Young of Hornsey: My Lords, like other noble Lords, I thank the Minister for his opening speech, especially the way in which he outlined the Government's plans for children in care, which is what I would like to focus on.
	First, I declare a few interests. My comments are informed by briefings from the NSPCC and the NCH. I am also a patron of the Post-Adoption Centre, which has been helpful in these matters. I should also state that although it was many years ago, I was closely connected with children in care and the challenges of living and working in the system. The Minister pointed to some of the dreadful statistics relating to this group, as has my noble friend Lord Ramsbotham.
	I am most grateful to my noble friend for mentioning the arts. It is usually me who brings up that subject. It is particularly important in this context, especially in terms of raising levels of self-esteem and enabling children and young people to be told "Well done; you have done something that is worth noting and you are worth something". Children in care particularly need to hear that.
	I return to some of the statistics. Three times as many children in care are cautioned or convicted for an offence as children of the general population of that age group. There is a very low likelihood of their achieving A-levels, given the appalling rates of achievement at GCSE level, and therefore a very low chance indeed of their going to university. In addition, care leavers are more likely to end up homeless and/or suffering from mental ill health—and, as my noble friend Lord Ramsbotham stated, in prison.
	With about 60,000 children in the care of local authorities, those facts represent a serious failure to enable thousands of young people to fulfil their potential. Sadly, the progress that has been made over the years since I was directly involved in the sector seems to have been minimal. I am therefore pleased to note the Government's stated intention to,
	"reform the statutory framework around the care system to enable children and young people to achieve high quality care and support and drive improvements in the delivery of services focused on the needs of the child".
	Surely few would disagree with that statement; so how is it to be made real?
	The intention to place the role of the designated teacher on a statutory footing and to ensure that children in care do not move school in years 10 and 11 unless there are exceptional circumstances are two measures that I very much support and welcome. A designated teacher can provide the continuity and encouragement to achieve that is so often lacking from the lives of those young people. Our educational system, with its focus on frequent testing, presents children with opportunities to excel and to experience academic achievement. For many looked-after children, however, bearing in mind the disadvantages resulting from their status, those become more opportunities to reinforce their sense of failure. Years 10 and 11 are crucial years academically, but, in my view, keeping children in care in the same school if they are happy there should be an aim throughout their education, not just in those years. It is disruptive for any child to move school, but if school friends and teachers are the only people consistently present in your life, it is all the more crucial for those relationships to be sustained.
	If a child in care demonstrates an aptitude for academic work—to be fair, that is not the be-all and end-all of education—what facilities and resources, both physical and human, are available to support and encourage him or her? What impact will raising the school leaving age to 18 have on young people in care? How will their specific needs be addressed? What kind of training and continuing professional development will be available for designated teachers to ensure that their skills and experience are up to scratch for that most vulnerable group? If such a young person manages to overcome all the obstacles and achieve the grades to go to university, where does that young person go during vacations if they are based in halls of residence? Who will be around to advise and mentor them and keep them going if they feel like giving up?
	Another government aim is placement stability, which again is crucial, and ensuring more consistency for children in care. That affects their educational and life chances. In 2005-06, 65 per cent of the 23,000 young people under 16 who had been looked after for two and a half years or more had been in the same placement for at least two years or were being placed through adoption. The target for 2008 is that that 65 per cent should rise to 80 per cent of young people experiencing that level of stability. Is the care system on track to achieve that figure?
	The NSPCC argues that:
	"Despite the acknowledged increase in Children and Adolescent Mental Health Services (CAMHS) funding, resources at all tiers of provision remain stretched, and the associated thresholds for assessment too high. Children in the care system do not, typically, receive access to therapeutic help from CAMHS unless they are diagnosed with a mental health disorder. This is not necessarily an appropriate measurement when assessing a child's need for therapeutic support".
	That is an important point and I look forward to hearing more in response to that statement. The chances of anti-social behaviour, self harm and a lack of self-confidence are much higher for children in care. They are also more likely to be bullied in school. I am inclined to think that therapeutic support ought to be more widely available for looked-after children.
	I do not want to give the impression that I see children in care as hapless victims of an uncaring state. On the contrary, many of those whom I have met are resourceful, intelligent and very good at seeing through platitudes and noticing adults who treat them with condescension. They want to be consulted in a meaningful way. They want to have some control over their destiny, not be consulted at the end of a process, when their views will be used as window dressing for proposals that have already been determined. We should therefore make strong efforts to enable young people in care to voice their opinions and perspectives on the key issues that affect them and open up the possibilities for a genuinely child-focused approach. I hope that the Government listen to those young people and take note of what they say both through their advocates and in an unmediated form.
	Children in the care of local authorities, whether in a children's home or in foster care, are likely to experience feelings of abandonment; to feel that no one loves them for what they are; to suffer from low self-esteem; and to feel that they do not belong. Legislation cannot make a child feel loved, but it can help to create the best chances of a child recovering from the devastation of being in care, for whatever reason.

Baroness Emerton: My Lords, I, too, congratulate the noble Lord, Lord Darzi, on his opening of the debate on such a wide number of issues with such clarity. It is with pleasure that I support the concept of providing a healthcare system organised around the needs of patients, as proposed in the forthcoming Session in the gracious Speech. I also welcome the approach taken by the noble Lord in the London review, the interim report and the continuing work for the total NHS.
	It is important in creating organisational change to meet the needs of patients and that patients are involved in planning in a very real way, not just a token involvement but in a participative way. I recently witnessed that by attending the opening of the Royal Alexander Children's Hospital in Brighton, the planning of which I was privileged to start several years ago.
	Children and young people were involved in the planning and formed a young people's board. They took a central part in the planning and delivery of the operational policies. That was not just a token involvement but a real participation, together with representatives of parents and staff. The board met in the presence of the chief executive, but a young person took the chair—each taking it in turn. There were proper agendas, minutes and briefing papers. For example, they designed the cubicle curtains, interactive sculptures and a new time capsule. They also created a new Alex website with a gallery on the web, where young people could show the artwork that they had produced while they were patients. They also developed a play philosophy in partnership with the Alexander staff, which has now been adopted, alongside some of the patient care pathways. Several awards for that innovative approach have been given and the media attention has raised the profile of the trust. That shows a genuine commitment to involve children and young people in their new hospital.
	The provision of patient-focused care is possible for every specialty from obstetrics through all the acute and chronic diseases, including end-of-life care, mental health, and learning disabilities, but it requires special skills for engaging patients in a real way, rather than through a token consultation. I declare an interest: as part of my role as a regional nursing officer, I managed the change of the closure of two large institutions, each having more than 1,000 patients with learning disabilities, and transferring them to community care, each having an individual programme following assessment. The whole exercise took 10 years and much patience, involving patients and their relatives, training staff and involving the local authorities, especially the directors of social services, in transferring the services to the community. It was costly, but that service is now proving to be well managed by social care with health services giving support to meet healthcare needs.
	The noble Lord, Lord Darzi, is spending much time listening to staff and local people in his continuing review of the NHS, and I hope that the innovative ways of involving patients in the design of the new healthcare system will take a hold and that various models of good practice will be delivered so that the quality of care can be raised cost-effectively and efficiently. The management of such changes calls for a change in culture. For some healthcare professionals, the involvement of patients poses a threat. There is no need for this if there is someone to champion change.
	"It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm",
	wrote Florence Nightingale in 1883. It may seem even stranger that Her Majesty's Government propose to introduce in the new Session legislation to create a stronger health and social care regulator with a remit to ensure a clean and safer service and a high quality of care, but the need has sadly been made evident by the two recent Healthcare Commission reports into hospital acquired infection. Again, I declare an interest as a resident living nine miles from Tunbridge Wells and seven miles from Maidstone, and I am very aware of the great distress caused to patients, to relatives and indeed to staff and the community as a whole.
	Having studied the reports very carefully, I see that there is indeed a need for accountability and authority to be strengthened from the point of delivery of care to the board, with 80 per cent of care being delivered by nurses. The urgent need is to ensure that the ward sister or unit manager has the authority and accountability to deliver safe care, supported by clinical teachers from the universities to assist in ensuring that theory correlates with practice. The Nursing and Midwifery Council requires 50 per cent of training programmes to be spent in the clinical area. However, with the pressures caused by an overheated system, with bed occupancy often in excess of 95 per cent or more, students very often lack supervision. This requires a review of workforce planning, taking account of patient pathways and the numbers required to be trained and to deliver care, by the Strategic Health Authority in liaison with the universities. The retraining of sisters at ward level is essential if infection is to be prevented and the environment managed, as is providing clinical teachers, possibly with joint appointments between the universities and the NHS trusts, as has already happened in some cases.
	None of this can be effective unless there is an officer accountable at board level for the delivery of care, and the board must be as committed to the safe delivery of care as it is to balancing the books. This requires a training programme for all board members and will be successful only if there is a change in culture. It is interesting to note that the only NHS trust to have no MRSA for two years was the Royal Marsden, where controlling infection is a high priority and where at board level there is an officer accountable for nursing, catering and cleaning.
	I have concentrated on hospitals in the time available to me, but the same principles apply to community care. There must be accountability from the point of delivery of care through to the board, and there is a need to review the workforce planning arrangements between the SHAs, taking account of patient care pathways and the number of training places to be commissioned with the universities both at pre- and post-registrations levels, with the inclusion of more joint appointments of clinical lecturers supervising the delivery of care.
	It must be a false economy to cut training budgets, which the noble Earl, Lord Howe, mentioned. The absence of accurate workforce plans is an even more false economy, as is cutting advanced practitioners and specialist nurses who provide effective care. I look forward to taking part in various debates on the new Bills.

Lord Pilkington of Oxenford: My Lords, I shall consider the proposed reform of examinations over the next decade, in particular the effect on vocational education. The problem is that this country has mishandled vocational education for well over a century. In 1902, the state created its own grammar schools. An examination system existed to sustain them, but even then vocational education was neglected. There was a reliance on very ancient apprenticeships, and the great technical schools of Victorian England, which were created by the whisky tax, were deliberately and very badly run down.
	By 1945, reform was desperately needed. In essence, the English state decided then, as it has continued to do, that the best way to improve vocational education and to give it prestige was to make it parasitic, or, if you like, to subsume it into the academic pattern, both in institutions and examinations. This was the thinking behind the comprehensive schools supported by both major political parties. I remember the cry that brain surgeons and plumbers would all be educated in the same institutions. The same argument was advanced when my party decided to amalgamate O-levels and CSEs in the 1980s. The idea ran like a seamless web through the whole system. Furthermore, the system of vocational examinations introduced from 1986 onwards failed to achieve a clear shape of vocational qualifications that were respected by the whole community. I should add that neither political party was prepared to take on industry and ask it to pay something and provide personnel to help to supervise and arrange vocational education. That fact rises above politics.
	Our continental neighbours faced exactly the same problem in 1945. Vocational qualifications were not valued and were seen as inferior to academic ones. However, they followed a different pattern. They created freestanding vocational schools, supported by generally recognised vocational examinations. In many cases, often under pressure from the state, industry had to pay something towards this and provide examiners for the courses. This was most successful in Germany, although it is true that Germany had a long interest in vocational education—Sunday schools in Saxony gave vocational education in the 1720s. Germany created its famous vocational schools—Berufsschulen—which are highly respected and combine traditional education with training for a trade. Austria does the same. In Austria, about 50 per cent of the relevant age group goes to vocational schools. The university system there examines people in detail right the way through, and many people drop out of the courses, but it is not such a disaster because they move on to vocational diplomas and then have a trade and respect and can earn money. Holland, Switzerland, and France to a degree, follow the same system.
	Although the noble Lord, Lord Adonis, is absent, I pay him the compliment that he has a genuine interest in academic excellence. However, I stay here on a Thursday afternoon to make this speech and to urge him and his colleagues to consider the continental experience. Merely trying to create an adjunct to A-levels will not work. To gain respect, vocational education has to stand in its own right, and have examinations that are recognised right through society. The Government have to be prepared to act with great courage and say to industry, "You've got to pay something towards this and provide personnel for the exams". If they do not do that, it will be another in a long history of disasters that began in 1902 and ran through to 1945. I remember the late Keith Joseph saying to me that he made a profound mistake in the 1980s. Let us hope that the noble Lord, Lord Adonis, avoids that.

The Lord Bishop of Ripon and Leeds: My Lords, I give a wholehearted welcome from these Benches to the Government's commitment in the proposed Education and Skills Bill to move towards the participation of all young people in education and training up to the age of 18 and to the ambition to make the country a world leader in skills, as expressed by the Minister in his opening speech.
	Churches have long been committed to a full and engaging educational experience up to the age of 18. We welcome the opportunity to work with the Government to meet those aims in schools and FE and HE institutions. It needs to be a commitment to an education that equips for life as well as providing skills for work. Young people should have, in the words of the Green Paper for the Education and Skills Bill, personal capabilities, resilience, interpersonal skills and attitudes—that is, people who are becoming whole and rounded adults.
	We welcome the emphasis on compliance within the Bill—on compliance from employers as well as from young people. We recognise that additional measures may be needed in order to achieve that compliance. As far as young people are concerned, the need is to make that provision as attractive as possible. Colleges must have as much richness, variety and depth of provision as schools have now. In schools, there is already the welcome availability, which could be developed further, of vocational courses and an increase in the number of 14 to 16 year-olds taking skills courses either in school itself or through local colleges. In school sixth forms, there is the valuable contribution of spiritual, moral and social development to the development of the whole person. This Bill will provide opportunities for those from deprived backgrounds to achieve greater status and recognition because of the higher status that should be accorded to skills education from 16 to 19.
	I welcome the apprenticeships emphasis, Train to Gain and employer-based training in general. I echo the concern expressed by the noble Lord, Lord Pilkington, for the new vocational diplomas and the way in which they actually work, both in terms of being credible to employers and in providing an opportunity for the personal development of young people, especially those with the greatest need.
	My own education between the ages of 16 and 19 appeared to have no interest whatever except in academic attainment and possibly sport. It would have been good had that education had some sort of emphasis on skills. Then, as now, however, there was little emphasis on what ought to be a strong core of our learning—on citizenship, spiritual and moral development, in order that we can develop a sense of meaning and purpose in our lives. This Bill and this moment provide an opportunity to do that at a crucial point in the life of our society.
	We talk a lot about community cohesion. We do a lot of work in Leeds, for example, to enhance good community relationships and provide support for families. All of that needs to be expressed within the 16 to 19 curriculum, and it needs to be properly funded. The noble Baroness, Lady Barker, spoke earlier about the need for proper funding for these among other developments. That hangs like a sword of Damocles over so much that is exciting in all the proposals that we debate today.
	I will take an example from the proposals for children in care in the place of residential family assessment centres and the removal last month of financial support for residential assessments despite a universal recognition of their value. The argument that was used was that it was the responsibility of local authorities. In many cases, local authorities believe that such assessments, however beneficial they may be to the families concerned, are simply too expensive. In a range of areas concerned with children and young people, local authorities must be properly funded if the aims of the proposals are to be achieved and if our society is to benefit from them.
	I hope that the Government, through the Education and Skills Bill, will take the opportunity to correct the anomaly over the entitlement to provision for spiritual, moral, social and cultural development, which 16 to 19 year-olds have in schools but not in colleges. That is an anomaly of the Education Acts 1944 and 1968 which did not cover FE colleges at a time when most FE students were on day release. In the Further Education and Training Bill of the past Session, the Government did not feel that it was appropriate to extend that entitlement to FE students. But now we have a broad vision in this proposed legislation which is quite different from the more technical concerns of the Further Education and Training Bill. It would be extraordinary to concentrate on specific skills and not to take account of those moral and social values that need to be at the heart of our community culture and therefore of our education system.
	Young people have so much to contribute to that culture and that can be helped only if we are prepared to look to the provision of education in moral and social matters within the work of the FE colleges. There also needs to be significantly more emphasis on that group of subjects within teacher training and the encouragement within FE of those particular parts of our being.
	This entitlement is about equality of esteem and value for all students up to the age of 18, whatever the appropriate pathway for their education. It is about supporting colleges in ensuring that students have the opportunity to explore and challenge their own faith backgrounds, their own particular faiths or their own lack of faith. The lack of availability of effective provision for students' spiritual, moral and social development on college campuses can leave them vulnerable to other sometimes extremist influences. This can then help to destroy the social cohesion for which we are all trying to work. The overall provision in colleges needs to provide the opportunity to celebrate and value faith and to explore social development within its overall provision. It cannot simply be left as an optional extra. Values appropriate to our multi-faith society need to be inculcated in the overall provision made through these groundbreaking proposals.
	The churches have a long history of engagement with skills education. We are immensely supportive of the aims of these proposals and I look forward to a fruitful discussion of the ways in which this can be a moment which is seized in the cohesion and coherence of our whole society through proper provision and support for those in the 16 to 19 age group.

Baroness Murphy: My Lords, I want to talk not so much about what is in the legislative programme on health—which is fine as far as it goes, and we shall have ample opportunity to talk about it—but about what I see as being missed out: legislative measures to support existing NHS reforms. The recent tragedy at Maidstone and Tunbridge Wells hospitals, to which my noble friend Lady Emerton alluded, where more than 90 people died of C. difficile infections, is no more than the visible tip of an iceberg of many NHS hospitals where we would not want our relatives to be cared for and where the standard of care is not only unacceptable but seemingly resistant to change. In my view, this is the inevitable outcome of 60 years of direct central management of the NHS from Whitehall.
	Some noble Lords will be thinking, "Rubbish", and that bad managers, second-rate clinicians and incompetent boards are to blame. As someone who has worked as a hospital consultant, a chief executive and a trust chair and who is now on the board of Monitor, the foundation trust regulator, I have direct experience of dealing over many years with the constricting chains of Department of Health management, where boards are regarded at best as largely irrelevant and at worst as a positive nuisance; where chief executives spend up to a quarter or more of their time "feeding the beast" while out at meetings of the hierarchy rather than on patient-related matters; where clinicians feel disempowered and removed from the responsibilities of management, although they spend all the money; and where the responsibility for training nurses and for generating the quality of care standards and so on is removed from the hospital to a remote body.
	I know that there are plenty of scandals in the independent sector care homes, too, which are the result of poor consumer pressure, no competition and ineffectual regulation. But in NHS hospitals it is the profoundly disempowering remote management that encourages NHS managers to fiddle with numerous edicts and instructions while the quality of services may be lamentable. The Government have begun to change things. Over the past decade of Labour government, and before that under Conservative Governments, there has been in this country a policy consensus that hospitals and community health and social care service providers must be freed up and moved from direct control to real, commercial-style autonomous boards with local accountability, where competition, plurality of providers and real choices for patients drive a regulated system judged on clinical and patient satisfaction outcomes, not on proxy process target measures.
	The system in health has been mirrored in the policy initiatives in education. We have come a long way in the past decade and I pay tribute to the Government for that. I have been very proud to be part of those reforms, which are now widely recognised as the right approach. Commissioners are focused on understanding local health needs and designing appropriate care pathways. There are real incentives for providers to give efficient, high-quality care through the payment-by-results tariff system and the introduction of real patient choice. Autonomous providers are free to make their own decisions on how best to deliver care that responds to patient and commissioner requirements quickly. The real challenge is whether the Government will keep up the pace of reform. Many of us have watched effective government policies slide into the ground, neglected and half-implemented after a change of Secretary of State. Stepping back at this stage will have grave consequences.
	But what was Gordon Brown's reaction to the news that, in the public's view, our hospitals are not getting clean enough fast enough? He issued an edict that all hospitals will have a ward-by-ward "deep clean" to rid them of fatal superbugs. He said that,
	"walls, ceilings ... and ventilation shafts",
	across the country,
	"will be disinfected and scrubbed clean".
	That is the Prime Minister speaking about hospital ventilation shafts. What will he do when that fails? Will he send David Nicholson out to scrub the bedpans himself? That would be a long job. The noble Lord, Lord Darzi, will say that all US hospitals do the deep clean as a matter of course. Of course, UK hospitals should, too. Indeed, they used to. I participated in the "high sweep" as well as the "deep clean". The noble Baroness, Lady Emerton, obviously has done so, too, as she is nodding vigorously. I have no quarrel with the need, only the manner of the directive and the fact that once again the centre will determine action, not because hospitals see it as their priority.
	The Government must not bottle out and regress to the norm of issuing instructions on cleaning or anything else. If we trouble to look at the history, we will realise that that will not do a jot of good. We must have the courage to be patient and to hold fast to the benefits that we are beginning to see from the reforms in, for example, the NHS foundation trusts, which are delivering higher-quality care than NHS trusts in general. They are delivering strong financial performance. Last year, they delivered a surplus of £130 million and are becoming more efficient. Those people who do not see the point of surpluses should remember that no surplus means no investment, no growth and no improvement. All 19 organisations rated as excellent by the Healthcare Commission for use of resources and quality of services are foundation trusts.
	There is growing evidence of the beneficial impact of greater autonomy on foundation trust boards and on managers and clinicians. At Monitor we have now seen more than 100 boards in our very rigorous assessment process. Boards are taking greater ownership of the performance of their trusts. They are and they feel accountable for performance. That is important. Chairmen and boards are starting to behave differently. They see their trusts as autonomous businesses and their role as driving performance, which recruits better chairs. Boards are adopting more professional management approaches with the introduction of service line management, which empowers senior clinicians to take responsibility for their services and puts them in the driving seat.
	Let us not forget that there are an estimated 800,000 members of NHS foundation trusts, providing a direct link to patients and local communities. What an opportunity we have to use those members and governors creatively to influence the way our hospitals perform. Yet the Government forget they exist. We need to use those governors and members, who are an excellent vehicle for linking patients and the local community to influence the hospitals.
	To slow the pace of reform now, to hint at any return to command and control, would put this at risk. I am told, and the noble Lord, Lord Darzi, has repeated it, that there is no intention to reverse the process of reform. But I hear different mood music, a subtle silence that will not do. The word "choice" has disappeared from documents. Competition from the independent sector is no longer talked about. Yet unless there is overt, visible drive, the reforms will stop. The great NHS machine will see to that. Rather than slowing down, the Government need to step up the pace of reform, to build up the capacity of commissioners and to improve the range and quality of information on clinical outcomes that are available to patients and the public, both to inform choice and to stimulate clinicians to improve their own results. We have the mortality data, which is a start. We need far greater outcomes data. We must support boards, senior managers and clinicians in developing the capabilities that they have to empower front-line staff and lead high-performing organisations.
	In Monitor we have tried to do a number of things. I have mentioned service line reporting. We have introduced with the Cass Business School at City University a tailored training programme for finance directors to help them to make best use of the freedoms offered to foundation trusts. We are developing a training programme for non-executive directors to help them to challenge their executive directors more effectively and to help to drive performance.
	The review that the noble Lord, Lord Darzi, is undertaking provides an excellent opportunity for the Government to cement their commitment to reform. If the reforms are combined with effective regulation, which I hope we will see from the forthcoming Bill, we will have a chance of sustainable improvements in our health and social care services.

Baroness Morgan of Huyton: My Lords, in speaking about the education section of the gracious Speech, I particularly welcome the emphasis that it placed on giving all a chance to fulfil their potential. In this context, I believe that raising the school leaving age is a symbol, offering to all that which is currently available to some. I am pleased, however, that this will be a phased-in measure, not taking full effect until 2015, as rushing quickly would be a mistake. After all, this will work only if the levels of overall literacy and numeracy from the early years through primary and secondary schools are raised for those currently underachieving. Alongside it, we need a renewed emphasis on the curriculum available for 14 to 19 year-olds and the rolling out of the much needed expansion of apprenticeships. I recall talking last year with a group of British Aerospace apprentices in Preston, who spoke enthusiastically of their renewed interest in learning. Finally they could see the point, as it was in the context of their new and exciting jobs. There is much to be said for learning from existing apprenticeship schemes.
	The comments of the Secretary of State for Children, Schools and Families about the obligation of the Government to offer a range of choices and a strong curriculum are very positive. If the raising of the school leaving age is seen predominantly as punitive rather than as an extension of opportunity, we are in danger of antagonising the very pupils whom we are seeking to reach, and I welcome the overall approach in this area. It is of course right, however, that schools, the Government, parents and pupils all have shared responsibilities. Our hope must be that legislation by 2015 becomes almost irrelevant because we will have reached almost full participation by that date. However, the promise of the legislation will, I believe, act as a bit of a kick to the system.
	That kick is still necessary. I am currently chairing a charity, Future Leaders, which trains potential head teachers for the most challenging urban secondary schools. It is focused and strongly mission-led, making it absolutely clear that excuses for failure are unacceptable. The lead tutor is a great former head teacher, Sir Iain Hall, who used to teach in the north-west. Every Friday he writes an uplifting missive to the participants. This week's communication was particularly pertinent. He writes:
	"Throughout life we make choices. We decide who we should live with, where we should live; what the quality of our life will be like; how we will spend our free time or, if we have any, how we spend our surplus money. We can make, or even unmake, these choices as we pilot our journey through life. Sometimes events may seem to overwhelm us, but even then, we can decide how to handle the situation. However, there are four aspects of this journey through life in which we had no choice. We did not decide who should be our parents; we did not decide our ethnicity; we did not decide our social class or even our gender. Each of these aspects of our starting points in life was decided for us. We had no say in the matter despite these choices probably being the most important determinants of our future. These determinants were, for us, an act of randomness ... It was as if our start in life, to some extent, was the result of a large slot machine ... with four giant rollers. The first roller would determine our parentage—married and stable or single parent. The second would determine our social class ... The third roller would determine our ethnicity, whilst the fourth would determine our gender. Far fetched? If you look at the starting points of some of our students in our schools you may not think so".
	On the whole, they are not there through their own actions, but through a range of other influences.
	Sir Iain goes on to ask us to imagine the consequences of the slot machine. With the first pull of the lever, he states:
	"Great result! You have scored stable family, middle class, white and a boy"—
	today it could be a girl as well.
	"The machine predicts a good life ahead of you. By the age of three you will probably have a vocabulary some ten months ahead of your peers. You will be twelve months ahead in the recognition of colour, shape and numbers. By the age of eighteen you are headed for university and, given a fair wind, a successful life".
	With another pull of the lever, the machine spins again:
	"English-Bangladeshi, working class, stable family and female. By the age of five you will already be twelve months behind your peers in terms of school readiness; you have a two in three chance of living below the poverty line; one in sixteen chance of being unemployed when you leave school and, just to add more troubles, only ten percent of our university students come from minority ethnic backgrounds".
	Let us try again:
	"Afro-Caribbean, single parent, male and working class. Your proposed future seems somewhat difficult as well. Statistically, you have a one in four chance of being delayed in your development; two in three chance of growing up in poverty; one in six chance of being unemployed between the ages of sixteen and eighteen and, if you don't gain employment by then, a forty percent chance of being permanently unemployed until you are at least twenty five".
	The machine is set for one last spin:
	"White, male, single parent and working class. The only difference between this and our first spin is single parent and working class, yet statistically the odds are now stacked against you. The greatest under-performers in our school system are now white working class boys. Having a single parent gives you a seventy percent chance of growing up in poverty; you have a one in eight chance of being unemployed at the age of sixteen and the same chance of entering university as our ethnic minorities. However, you will not be alone. In 2005 there were 220,000 young people who were not in education, training or employment".
	They have plenty of company, but not much likelihood of success.
	Sir Iain then urges the participants, these future head teachers—whether they had a lucky start in life or managed themselves to break through the barriers, perhaps because they had the opportunity of attending a great school—to help those in the coming generations to break through these barriers, too, and to help pupils to raise their sights by delivering to them the education that they clearly deserve. That almost missionary zeal to raise the life chances of disadvantaged children through education is one that I believe we all can and should support. It is no longer acceptable, thank goodness, to be fatalistic and explain failure in detail. Our responsibility is to deal with failure and underachievement.
	There is another group of children not picked up in those Rowntree Trust figures: children in care. The low achievement of these children is well documented and I am delighted that the Children and Young Persons Bill will offer protection for older children and minimise school movements, both very worthwhile measures. I know that we will spend a good deal of time debating those issues in this House.
	It is vital that, in addition to the new Bills announced in the gracious Speech, there is continued effort on the basics, the building blocks of achievement. So there can be no let-up in the concentration on literacy and numeracy skills; without them, a wide-ranging and fulfilling later education is impossible. I would urge further consideration of, as Jim Rose advocated, the use of synthetic phonics in our schools. I confess personally that, if a school is not achieving high literacy rates and is not choosing phonics, I would want to know why. In this area, as in so many others, intervention is both justified and necessary.
	The Prime Minister's recent speech on education emphasised that the Government will close failing schools quickly. That has to be right. We cannot stand by and let a generation of young people fail in case the school gradually improves a bit. The extension of city academies in this context, particularly sharing the expertise of leading independent schools and universities, is very welcome.
	The recipe for great schools does not change; for me, it is a concentration on teaching and learning, a focus on literacy and numeracy until students reach an adequate level using whatever extra help it takes at whatever level of schooling, a strong school ethos with clear codes of behaviour understood and operated by the whole school community, the expectation and celebration of success and, crucially, a great head teacher leading a committed team.
	Recently I visited a school in Liverpool, the North Liverpool Academy, formed by the amalgamation of two poor comprehensive schools. It is in one of the most deprived wards in the UK, where the head and her teaching staff are totally focused on transforming the opportunities for the pupils by concentrating on each student, one by one, and stretching them to go as far as they possibly can achieve. That focus and commitment was humbling and the response of the pupils remarkable. Yesterday I spoke to the head teacher, Kay Askew, to ask her permission to mention the school to noble Lords today. Her response was, "Yes, please, but you must tell them this". I promised that I would, and she went on to say that,
	"the students are really trying with their work and their attendance ... they are joining in, putting on shows for charity, making shoes boxes for Christmas, running football coaching in the community and many other citizenship contributions. The staff work their socks off to make really focused dynamic lessons with a variety of experiences for the students and help them by giving up many Saturdays and weekends to catch up and revise. We also could not be where we are without our many community partners who have worked for years to bring the Academy to fruition and especially ... a very dedicated sponsor. One of the real successes has been the parents and how they turn out for the students to our many evening events. On Tuesday we are having a Pink and Powerful day to support Women's Enterprise day where we will show that you can be ... fashionable trendy and successful in a career".
	Kay Askew is right to be proud, as she clearly is. It is in schools such as this that we can really deliver the opportunity for all, for which we strive. I look forward to our debates around this subject in the coming year.

Baroness Howarth of Breckland: My Lords, the gracious Speech outlined by the noble Lord, Lord Darzi, certainly has vision, as the noble Lord, Lord Warner, said in his inimitable way, but vision has value only where it has application, and the government programme will succeed or fail on its implementation and outcomes. Remember: aspiration is not achievement. As deputy chair of CAFCASS, I know that only too well, having moved into an organisation whose conceptual framework was excellent but whose application and implementation were chaos. Fortunately, with a strong board and a superb chief executive, we now have an organisation serving more children than any other social work department, and serving them well. But it shows that you have to have a clear plan of implementation whatever the concept of the vision.
	The Government tell us, for example, that they want the best for children and young people, especially children in care. I know that that is a continuation of the Every Child Matters agenda, on which I congratulate the Government, but there remains much to be done. I continue to watch with care and interest—I will no doubt come back to the Minister on this at some point—the way in which Ofsted inspects some social care services.
	We know that children want to be heard, to be emotionally understood and to have continuity in their care, but that can be achieved only if we have the right professionals in place. In his discussions the Children's Rights Director, Roger Morgan, was told of the importance of social workers in the lives of children and young people in care—indeed, one in three of the children and young people in his survey saw them as among the most helpful and important people—and yet we still fail to value them. Consequently, there is a high turnover in many areas and it is extremely difficult to recruit, particularly in London.
	Surely the children's voices should be heard here. So perhaps I may quote one young person who, looking back on their time in care, said:
	"with children in care, they need to always know they have someone to turn to and talk to. I never felt that. I ended up in and out of prison and felt I had no support. The longest I had a social worker was three months then from there I've had 14 different social workers".
	Contrast that with the experience of a man called Michael, who came into care at birth. His childcare officer saw him through placement breakdown and approved schools into a secure foster home and through the formation of his own secure family—50 years of contact. He credited much of his emotional security to her and his foster families' consistent emotional connection to him. Of course there were care plans, but he received what another child described as wanting from their ideal social worker:
	"support, advice, friend, someone I can trust, someone I know really cares about me, not just a number or a client they don't really care about".
	I do not expect that every child will have a care worker such as the one I have described, but does the Minister think that we will come anywhere near this in the new Bill while we continue to undervalue and underpay the social work profession? Will he not commit himself again to improving conditions so that children have people with the right skills and attitudes to meet their needs? It is that and not more structural change that will achieve what I know the Government and the Minister seek.
	As I am speaking of children in care, perhaps I may raise an issue that came to mind during the debate. If we are trying to keep children in placements consistently, what will the Government do about school exclusions? Many children with difficult backgrounds are difficult in class and in some schools there is great encouragement to exclude them because of the difficulties they cause for others. There is a real conflict of interests here and I should be interested to know how the Government intend to tackle the issue.
	The question of value arises also in other fields. For example, does the Minister consider it appropriate that support workers for young adults with challenging behaviour that stems from learning difficulties—whose tasks require skill, a capacity for careful risk assessment, and the charge of these young people on behalf of their parents—should be paid barely above the minimum wage? I recently heard that a cleaner at Heathrow could earn almost as much as a support worker working with people with learning disabilities.
	One example after another—it is only shortage of time that prevents me giving further illustration—seems to demonstrate that personal care has become the poor relation in health, education and the social care spectrum. That was stated far more eloquently than I can by the noble Earl, Lord Howe. I would like the Minister to reassure me that when the legislation is introduced to create what is described as a strong health and social care regulator, social care will have as central a position as health.
	Social care increasingly affects more people than health, yet we spend huge sums on acute services to save people with brain injuries or premature babies, only to tip them out into an inadequate postcode lottery of community support services. If you bust your head in a car accident and survive, most likely with serious personality changes and physical disability, you may be lucky enough to be in the catchment area of a brain injury support unit such as the Grooms-Shaftesbury in Suffolk; but you are much more likely to have very little indeed apart from your frantic family, and we know that many of these families break down. We need a regulator who, apart from monitoring existing services, is able to say something about this; a regulator who has the same commitment to users as the Commission for Social Care Inspection has demonstrated under the leadership of Dame Denise Platt. Progress since the commission's inception has been strong, with an increase in 2005-06—for the fourth consecutive year—in the average percentage of minimum standards met in the services inspected by the commission.
	The commission also drew attention to the matter raised by the noble Baroness, Lady Barker, which I also emphasise: the gap in the legislation protecting the human rights of elderly people in private homes. I hope that we can fill that gap during this Session.
	As the Healthcare Commission merges into the new super-regulator, the Care Quality Commission, I would ask the House to ensure that, in its consideration of the Bill at all stages, the voice of social care is strongly maintained and carried forward. It would be wrong not to note that there are serious concerns in the social care and voluntary sectors about the proposed merger. Too many people are closely affected by these services. Any of us sitting in this Chamber, our friends and our families might need to use those services.
	The commission has led much of the debate on improvement. It has championed individual budgets and direct payments, examined the workings of the market for care and carried out a range of well-regarded and important studies. I would therefore ask the Minister whether it is true that, as the legislation is currently drafted, the new commission will be precluded from producing reports or studies until 2010, and then only after an annual discussion with the Secretary of State. I thought that the new Government were to be more open and transparent. If the position I described is true, it smacks of extraordinary control over the facts being collated by the new commission in its wider role.
	Whether it be for vulnerable children, people with a variety of disabilities or the steadily increasing numbers of frail elderly people in need of support, social care is vital to our civilised society. To meet this need it must not be lost in other services but be a true and equal partner with health and education, meeting the aspirations of our people to enjoy a full life and to experience emotional—as well as good physical—health and well-being.

Lord Soley: My Lords, I welcome the emphasis in the Queen's Speech on children and education. The Government's emphasis on those areas over the past 10 years will make it hard for future Governments of any complexion to reverse the progress that has been made.
	I want to touch on the issue of parenting, one of those issues that are profoundly difficult for politicians and Governments to talk about and yet intensely important to the quality of an individual's life and the society we live in. Recently I have seen headlines, not just from the Leader of the Opposition but across the board, about how we live in a "broken society". We really do not, and the evidence for that is very strong. I understand how, if you read the newspapers every day, particularly about what young people are doing, or indeed watch too many episodes of "EastEnders", you might come to the conclusion that the British public generally, not just young people, could be put into two boxes: one marked "Psychopathic killers" and the other "Depressive and addictive personalities". Actually, society is much better than that. The polling that was reported on the BBC recently, showing that about 70 per cent of people regard their family life as being high quality, is much closer to the truth. It is time that we started paying attention to the successes in this area.
	As I say, talking about parenting is always difficult for politicians and Governments, but it runs through much of what they are trying to achieve. It interests me that the teenage years—which are a nightmare for teenagers and parents alike, incidentally—are the ones that we find most difficult to deal with. Schemes such as Sure Start, of which I am a great supporter, and the child trust fund are profoundly good at the early years stage, and we are getting much better at helping parents and families to deal more effectively with the early stages of life. When it comes to the teenage years, we all seem to back off a bit because it is so difficult.
	It does us no harm if, whether as parents or as people who do not have children, we sit down quietly in a corner somewhere and remind ourselves what it was we did as a teenager—not all the good times we had, but the things we did that were both bad and deeply embarrassing. When I have done this exercise, it has often taken me so long that I have had to come back to it at a later stage and say, "I have a lot more work to do on that". I suppose I should not go too far down this road because the Bishops might say, "Yes, we agree with you", and I will end up doing "Thought for the Day" on Radio 4. What is important is not just that the exercise is good for your soul, but that it puts you in touch with your feelings as a teenager and therefore with some of the problems teenagers face today, which are not essentially different from what they used to be. There are some differences—the availability of drugs, and things of that nature—but by and large teenagers' problems are not that dissimilar. It is important to try to understand that.
	Any Government will have to face the problem of how to help parents address their anxieties and concerns during their children's teenage years. Almost any parent will tell you that it helps in difficult situations to talk to other parents. Often that shared experience will enable you to think of other ways to handle a problem presented to you by a young person. I am not sure how we could do that; I simply say to the education Minister, who has been very thoughtful on areas like this, that we need somehow to make it easier within schools and other educational establishments for parents to meet and discuss these issues. We also need to use the internet more imaginatively. There are websites where you can share your experiences of parenting, but they are limited and often hard to find. Finding ways to enable people to talk about this is more helpful than we might think.
	Quite a few years back—in 1994, if I remember rightly—it was the United Nations Year of the Family. I was an MP at the time and held some useful committee hearings in the House of Commons, which some noble Lords who were not Members of this House at that time had a hand in, as did the noble Lord, Lord Northbourne, who was a member of that committee, although he is not with us today. Many of the lessons that came out of those hearings have been picked up on, although not all of them by any means. What we need to do about parenting is not so much legislate for it—Governments cannot lay down ways of parenting—but rather enable a discussion to take place on the issue rather more effectively than has been the case.
	One of the problems Britain has as a society is that we are far less likely to intervene when we see young people behaving badly in public. Although I am quite happy to sit down and look at all the bad and embarrassing things I did as a youngster—and therefore I hope I am a bit better at understanding such behaviour—that does not mean I think we should not intervene when we see it happening in the street. We should, and at the end of the day most young people will welcome that. It is not easy, though; anyone who has tried to intervene, as I myself have on a number of occasions, will have noticed that everyone else on the bus buries their head in their newspaper, or finds they are looking on the floor for a coin they might have dropped, or something of that nature.
	We are quite curious in Britain in that we do not wish to get involved, and yet at the same time we often lay down conditions on risk-taking for young people. We go to the other end of the scale when children are taken out on expeditions and there is an accident, perhaps even a tragic death, and the next thing you know there are headlines asking who is to blame. The blame culture stops kids taking risks—but we have to take risks, even if tragedies happen from time to time. We also have to encourage involvement by adults. We have a strange balance. We are less good at this, unlike quite a few other cultures, particularly in the Mediterranean. This situation is not unique to Britain—it is more a problem of northern Europe—but it is quite pronounced here.
	We have specific problem areas such as alcohol and drugs, where there is much more work to be done. Black-on-black gun crime has caused a lot of problems in the area I used to represent, Shepherd's Bush. All these problems have a parenting aspect. It does not follow, incidentally, that the parent is to blame; sometimes they will be caught up in a situation and a series of events they feel they have lost control of. Alternatively, they might just have opted out and not be pursuing their role any longer. That is why we need to have a wider debate on parenting, although not in terms of what is "good" or "bad". I have yet to find, as has anyone who knows anything about this, an acceptable definition of "good parenting". The old phrase, quite rightly, used to be "good enough parenting". Ultimately any parent will have periods of good parenting and bad and it can be very hard, particularly at the time, to judge which is which.
	Then there is the broader question of how we deliver our public services. I wrote a paper a couple of years back and had discussions with people who were not then Ministers but are now—James Purnell was one of them—on shifting, not away from the idea of choice, because that is still important, but towards the idea of personalising and customising public services. That applies particularly to areas such as education, health, housing and so on, where the approach needs to be "How do we help you solve your problem?" and "How do we help you deliver the service?". A number of people already support this idea. I notice the words "personalising" and "customising" in the Government's lexicon now, and I welcome that. It is not easy, though, and the devil is in the detail. Indeed, it was mentioned earlier today that we ought to give people who are spending money on social care their own financial package to spend as they wish. That is a good idea and I support it, but we should bear in mind that the difficulty lies in the detail: in the first instance where such money is used inappropriately, whether for good reasons or bad, and the state then has to step in and provide it again or else leave the person by the wayside, you can imagine the headlines.
	Personalising goes on much more in education. If a child at a school—it may not be a child who is failing or of great intellectual ability but one who comes somewhere in between—has particular educational needs, he should be brought forward in certain studies that he could be good at but does not do well in at the moment. There needs to be a way of identifying that and personalising an additional educational package to help that child through. We should not think of this applying just to gifted children or to those with problems; rather, we should think of a range of things that would work well for the child and ask how we could put together a package of educational provision outside as well as inside the school. Such a package should be put together in consultation with the parents and the school so that the child's life chances are improved; in other words, we need to identify the problems and work on them with the parents and the family.
	I think that we are going down that route and I very much welcome it. However, it is a lot more challenging than people think. We should not think that it is common sense and that we can all do it. All sorts of problems are attached to delivering the detail but I am sure that it is the right road to go down. The idea of customising and personalising public services has to come high up in our thinking on public services in the future, because it is what people now expect. That expectation is not simply of a broad general right to a public service that will remain but of a right to a service that will in some way be better at delivering in relation to specific needs.
	I hope that we ensure that those thoughts run through our legislation but, above all, perhaps we can start the debate on parenting when we discuss some of the Bills that come out of the Queen's Speech. We need to share this very complex problem with which all people struggle in one way or another. We do not have any answers to it and government certainly cannot solve it but this discussion is important.

Lord Colwyn: My Lords, the gracious Speech refers to a commitment to providing a healthcare system organised around the needs of the patient and thus it enables me once again to draw noble Lords' attention to the current situation affecting the provision of NHS dental services.
	The Minister will know, as did his predecessors—I see that the noble Lord, Lord Warner, has just left the Chamber because he has heard all this before—that I support the concept of change in NHS dentistry and have commended the Government for their courage in tackling a dental service that has long needed revision, an end to the fee-per-item-of-service treadmill and help for the less well-off. But the dental profession, which is providing the service, does not believe that the new contract is working. The Government need more courage to consider changes; they need to undertake urgent discussions with the profession and all providers of NHS dental services so as to put the contract back on course.
	In 1999, the Prime Minister pledged that by September 2001 everyone would have access to an NHS dentist, no matter where they lived. In March 2006, on the eve of the new contract, 46.2 per cent of patients were registered with an NHS dentist. There are no figures for registration since the new contract, so it is difficult to assess the number of patients who now have regular dental care.
	The new contract was introduced to improve access, but recent surveys have shown that only one in five NHS dentists is taking new NHS patients and that four out of five restrict access in some way. Most dentists believe that the new dental contract has failed to make it easier for patients to get an NHS appointment and that the quality of care that patients receive has got worse. According to the recent Dentistry Watch survey, commissioned by the Commission for Patient and Public Involvement in Health and published on 15 October 2007, about 20 per cent of all patients are declining treatment because of the cost and about half of all patients simply do not understand the charges system.
	The new contract in 2006 gave primary care trusts responsibility for commissioning NHS dental services using a fixed budget set by central government. The National Audit Office has cast doubt on the ability of the PCTs to commission dental services. It found that the PCTs had little experience of high street dentistry and would need to ensure priority for the delivery of appropriate contracting arrangements, expertise and resources. The contract was not fully negotiated with the profession, to the extent that 1,649 dentists withdrew from the NHS between March and June 2006, just as the new contract was implemented. According to figures published by the Department of Health on 23 August this year, patient charge revenue generated only £475 million instead of the expected £634 million, resulting in a £159 million shortfall in the dental budget.
	It may be helpful to noble Lords if I explain that, under the system of dental charges introduced on 1 April 2006, the previous list of 400 individual charges was reduced to three price bands: band 1 at a cost of £15.90 for a basic examination, radiographs and cleaning; band 2 at £43.60 for single or multiple fillings, extractions or root canal work; and band 3 at a cost of £194.00 if construction work such as crowns is included. The new system means that the minimum charge for a treatment, which was previously £6, has risen more than two and a half times. The money paid to dentists, which is dependent on the number of units of dental activity accumulated, does not reflect the amount of work carried out. For example, dentists receive the same amount of UDAs from the primary care trust for treating a patient regardless of whether they do two fillings or 10. The number of UDAs awarded is not necessarily related to the time taken to complete the treatments. I understand that this can create a swings-and-roundabouts situation but it is not conducive to carrying out the best possible treatment for each patient.
	At a meeting of the Westminster Diet & Health Forum on Tuesday this week, I mentioned that 1.4 million fewer people receive NHS dentistry than did at the start of the new contract. I was corrected by Dr Barry Cockcroft, the Chief Dental Officer, who told me that access over the two-year period has remained broadly stable, with a 0.1 per cent fall of 47,000 according to the latest Department of Health statistics. I have the highest regard for the Chief Dental Officer, who is a brilliant champion and defender of the changes made by the Government. He has worked for 27 years in NHS general practice and has been closely involved with local dental committees and the task groups that formed the basis of the Options for Change report. His skills in the negotiation, explanation and implementation of the new contract are commendable, but sadly the views of the Government, the Department of Health and Dr Cockcroft are at variance with those of most of the dental profession.
	Most dentists want to work for the NHS to provide a quality, preventive dental service, but the contract is seen as being flawed and this opportunity is being denied. The Government have created a system based not on prevention but on a new treadmill, creating the unnecessarily prescriptive system of monitoring output via units of dental activity. Specific oral health advice, spending time with patients and advising on diet, smoking, drinking and good personal oral health regimes, does not attract any units, although I am aware that next week all practices will be sent information on evidence-based prevention and primary care and how this should be provided under the dental contract.
	I think that when the Minister, the noble Lord, Lord Darzi, made his recent statement on obesity, he agreed with me that the dental profession should be in the front line in providing advice to patients on nutrition and diet. Good oral health is vital for good general health. Promoting the potential of fluoride either in toothpaste or by targeted water fluoridation will reduce tooth decay significantly. I should be grateful if the Minister could confirm the Government's continued support and funding for the British Fluoridation Society.
	The British Dental Association is suggesting that a range of performance indicators should monitor dentists' activity, rather than reliance on the UDA as a predominant indicator. These should be agreed locally between the PCT and dentist contractor, based on the practice profile and the needs of local patients. Indicators may include numbers of patients seen and time and provision of additional services in conjunction with UDA monitoring.
	Rather than relying on 25 per cent of the dental commissioning budget coming from an unpredictable amount of patient charge revenue, PCTs should receive their dental commissioning budget in full. This would provide PCTs with financial certainty and allow them to commission the maximum amount of NHS dental services. I welcome the announcement that the Health Select Committee in another place will undertake an inquiry into dental contracts, including the general dental contract and the NHS personal dental services agreement.
	I welcome also the publication on 1 November of the London Assembly report on NHS dental care in London. It highlights concerns over the way in which NHS dentistry is delivered and calls for the department to revise the contract to encourage preventive care. Oral health across England varies widely and London is at the bottom of the list. In his Statement on obesity on 17 October, the noble Lord, Lord Darzi, said that he might look at the allocation of UDAs in respect of prevention. The report calls for revision of the dental contract to see how it might be possible to build preventive care into the equation. If the noble Lord, Lord Darzi, is responsible for that, I congratulate him.
	The Government need to trust the profession and to make the profession feel part of the NHS family. The Minister will be aware of the number of times that I have drawn attention to the absence of any reference to the dental service in government NHS policy. About 120,000 people work in NHS dentistry, including dentists, nurses, receptionists, practice managers, technicians and members of the community and hospital service. They should be consulted and represented and their contribution should be recognised. I shall look forward to hearing the Government's plan for the future.

Lord Harries of Pentregarth: My Lords, from the gracious Speech, I intend to focus only on the Bill to regulate human embryology and fertilisation. I must declare an interest as a member of the Human Fertilisation and Embryology Authority. The 1990 Act, which accepted the main recommendations of the committee chaired by the noble Baroness, Lady Warnock, has been a remarkably robust piece of legislation, as the Minister rightly pointed out. It provided a legal framework for the regulation of both treatment and research involving the use of embryos outside the body that has stood the test of time and has been deeply respected in other parts of the world. It has meant that public confidence, so vital in the area of evolving research, has been retained and that top-class researchers, who need a stable research environment, have been drawn to this country.
	It is only 17 years since that Act, but, since then, things have moved on most remarkably. Scientific advances, not envisaged by the framers of the 1990 Act, need to be regulated. In addition, social changes, already embedded in law, have taken place that Parliament will need to consider and evaluate in relation to this regulation. I therefore welcome the fact that we have a new Bill before us.
	The process whereby this Bill has come before Parliament has been a model of good practice. Consultation has been going on for at least two years, if not longer. First of all, the HFEA and stakeholders in the field were allowed significant input at the drawing-up of a consultation paper. The consultation paper was then widely discussed and input received by the Department of Health, before a draft Bill was brought before Parliament for pre-legislative scrutiny, the importance of which was rightly emphasised by the noble Baroness, Lady Barker. The Joint Committee set up for the purpose received evidence from a wide range of opinion and made a report to which the Government responded, before drawing up the revised Bill that we will consider. It has been a long and thorough consultative process, which is the very epitome of good parliamentary legislation.
	Like other noble Lords, I acknowledge the willingness of the Government to change their mind over one crucial feature of the legislation. It was originally proposed that the Human Fertilisation and Embryology Authority and the Human Tissue Authority should merge to form one new body, RATE, which would be responsible for regulating both fields. It has long seemed to the professional bodies that are most involved that the two areas were so different that a single body could not regulate both of them without losing a great deal of expertise. That view was strongly endorsed by the Joint Committee, whose recommendation the Government accepted, even though the path to a merger had already been travelled for some time. When a Government change their mind in that way, in response to the best informed opinion, that should be commended as a sign of strength, rather than derided as an expression of weakness.
	Another aspect of the Bill illuminates the wider question of the relationship between Parliament, regulatory bodies and those who work in the field: the possibility of cytoplasmic hybrids. It is right that major issues of principle, about which the public are hesitant if not hostile, should be decided by Parliament. A regulatory body regulates only on the basis of what Parliament has decided, making general decisions about good practice, while properly leaving other decisions to professional bodies and clinicians. The legal advice to the HFEA was that cytoplasmic hybrids were embryos within the meaning of the 1990 Act and were in principle within our remit to regulate. However, it seemed to me—this is a personal view—that this is a development of such significance that it is absolutely right that it should be considered by Parliament. The HFEA initiated a major consultation. Scientific researchers, initially frustrated about delays to their research applications, were later understanding of the need for a major development such as this to be considered by Parliament. I am sure that the noble Earl, Lord Howe, was absolutely right to raise the important question of the right balance between the respective responsibilities of Parliament and a regulatory body such as the HFEA. On this issue, the balance is right, and it is right that Parliament should consider it. A good number of highly significant decisions have to be made by regulatory bodies—they cannot look to Parliament all the time—but fundamental issues arise which should be so referred. Although I support work on cytoplasmic hybrids, I welcomed the wide public consultation and the prospect of a debate on them in this Parliament.
	The strength or weakness of a Bill such as that coming before us will be in the detail. A great deal of consultation, thought and care has already gone into that detail. Nevertheless, the Committee stage, when we look at the Bill clause by clause, will be crucial.
	As well as allowing for new scientific developments, the Bill takes into account changing social attitudes. There was a time, as the old song put it, when love and marriage went together like a horse and carriage. They went also with sex, pregnancy, birth and children being brought up by that couple. In the 1960s, with the advent of reliable contraception in the form of the pill, the link between sex and pregnancy was decisively broken. Since then, advances in medical techniques and changing social mores have combined to break the nexus of marriage, sex, pregnancy, birth and upbringing at every point. I take just one example: it was reported not long ago that a single Japanese woman in her 60s, who had gone to America to have a donated embryo implanted in her womb, had given birth to a child.
	The one moral principle to emerge with increased force from this great social change is that of informed consent. This is a key principle in both treatment and research, and the HFEA takes it very seriously—a good number of clauses in the Bill deal with it. However, if that informed consent is in place, what grounds do others have to refuse what a woman says she most wants? The noble Lord, Lord Winston, states in his book, A Child Against the Odds, that his overriding concern as a clinician is the health of the mother and any baby who might be born; otherwise, he states, he respects,
	"the right of women to try to have children".
	As parliamentarians, we have to ask also whether there are wider, social reasons for particular requests not being granted. If such requests are to be refused, there must be good, convincing, grave reasons; otherwise, the principle of informed consent will remain the only and the overriding consideration.
	We have all heard that amendments might be made to the Bill, either to make abortion easier in the early stages of pregnancy or to make it more difficult for someone to obtain. If so, there will be a great deal of strong debate around these propositions. We must not forget that this Bill is primarily about legislating for treatment and research. It is an important Bill in itself, and the good legislation of the 1990 Act, the extensive consultation that has gone into this Bill and the willingness of the Government to listen and change their mind over one crucial proposal have set a good precedent for us doing as well for people who wish to have children, and the whole sector, in the future as our predecessors did 17 years ago.

Baroness Warwick of Undercliffe: My Lords, it is a pleasure to speak on this Queen's Speech debate on education, health and social affairs and to congratulate my noble friend Lord Darzi on an authoritative and convincing opening speech.
	Noble Lords will be interested to know that at least eight Bills mentioned in the loyal Address have the potential to affect the higher education sector in one way or another. They range from the Climate Change Bill, through Bills on employment and healthcare, to the Pensions Bill. To me, that is a clear indication of the centrality of universities to our economic, social and political welfare and of their scope and diversity in today's world. Apart from their vital role as institutes of learning, they are employers of 1.2 per cent of the whole UK workforce and generated £43 billion of output in the economy. They are key suppliers of employees to every other sector, including business, industry in general, creative industries and the health service.
	Today I shall speak on just two Bills mentioned in the loyal Address—the Education and Skills Bill and the Sale of Student Loans Bill, and briefly to touch on health-training matters in conclusion. I declare my interest as chief executive of Universities UK.
	The Education and Skills Bill will see the age for compulsory participation in education and training raised to 18. As the Secretary of State for Children, Schools and Families has said, this is one of the biggest changes to the education system in more than 50 years, and I agree with him. There is an economic imperative to raise the level of skills in our young people. We need to increase participation in higher education to levels that match our international competitors. China and India are racing ahead in the globalised economy and highly qualified young people are either graduating in those countries or coming over to the UK to complete their studies in ever-increasing numbers. If we are to remain globally competitive, we cannot afford to waste the talent that we have in this country. There is also a moral imperative, which says that each young person should have the opportunity that enables them to unlock their potential. These moral and economic drivers are, of course, entwined. This is exemplified in the new diplomas, which will come on-stream in 2008 and have been developed explicitly to help to maintain interest in education by expanding the range of opportunities available to the post-16 generation and to marry the theoretical and practical worlds.
	Raising the participation age to 18 is not the full story, however. From 2011, there will be a demographic downturn, whereby the number of 18 year-olds will decrease quite substantially. There is even more to be done in training and retraining the existing workforce, as highlighted by the noble Lord, Lord Leitch, in his report on skills. It is salutary to note that 70 per cent of the 2020 workforce is already working; much of the upskilling and reskilling will take place in part-time or bite-sized courses, from HND or foundation degrees to first, second or even third-degree level. Those will be delivered in responsive and flexible fashion by our colleges and universities, even as they too continue to raise awareness of opportunities offered by higher education.
	Our universities have an increasingly important role to play in this agenda, offering courses that students want to study in the way they want to study them. While more members of the population are reaching the level of higher education qualifications—that is, level 4 and above—we cannot ignore the rapidly changing needs of our workforce. The higher education sector is committed to further growth and will respond to these changing patterns of demand. In addition, universities and colleges will continue to sow the seeds of interest in higher education as widely as possible. They already work with schools to raise awareness among their students to the opportunities available to them, and I can give your Lordships an amusing example. At Liverpool University, a Professor Fluffy—a cuddly character who is indeed fluffy, as she is a fluffy ball topped by a mortar board—visits primary schools in greater Merseyside to teach the very youngest children about student life and the possibilities ahead for them through higher education. In fact, so successful has she been that the then DfES used this as part of its wider Aimhigher campaign. Of course, more needs to be done by schools themselves. Improved school performance needs to be combined with high quality comprehensive information, advice and guidance to young people on the range of options that they can choose. Better careers education is required, which will grow into future university applications.
	The second piece of legislation to which I wish briefly to refer is the Sale of Student Loans Bill, in which the Government hope to realise around £6 billion from the sale of the student loans debt. Perhaps as an aside, I could urge my noble friend to spell out how safe and indeed circumscribed this sale is. While it has been done previously—in 1995 and 1997—I suspect that the current turbulence in the money markets might raise unnecessary anxieties about this approach. It seems a sensible and prudent approach but it leads me to ask wider questions about the financing of the higher education sector.
	I commend the Government on committing themselves to maintaining the unit of public funding for teaching in the recent spending review. I welcome their continuing commitment to university research, as well as the additional funding for the higher education innovation fund. However, the financial climate is increasingly volatile and an investment backlog still remains; the higher education sector needs stability to plan for the future. It would be heartening if the Minister could assure me and other noble Lords, as well as the higher education sector, that at least some proportion of the money raised by the Sale of Student Loans Bill, when enacted, could be reinvested in higher education.
	Finally, this is a debate on health as well as education and social affairs, and it would be remiss of me not to highlight the higher education contribution to the health service. The noble Lord, Lord Darzi, will be aware of this great contribution from his work at Imperial College. The higher education sector trains the vast majority of doctors, dentists, nurses and other allied health professionals in this country. However, the past financial year has not been easy; universities are still feeling the pinch from strategic health authorities cutting their education and training budgets, which has placed further training places in jeopardy. Can the Minister offer assurances to the higher education sector that the Government will look at returning to the situation in which the education and training budgets for nursing and allied health professions are ring-fenced and properly protected, and perhaps even look at placing these budgets with the funding council? That is already the case with medical and dental training and would prevent a recurrence of the boom and bust approach to workforce planning in our health service.
	To conclude, it is clear that the higher education sector continues to be integral to the fabric of this country and to its social, economic and cultural success, as well as making a vital contribution to the personal lives of all our citizens. I look forward to the passage of the Bills mentioned in the loyal Address to ensure that that success is taken forward.

The Earl of Listowel: My Lords, I give the warmest of welcomes to the Children and Young Persons Bill and the Housing and Regeneration Bill. I hope that the first will prepare the time when children taken into public care can expect at least as good an education as their peers and can expect to stay with the same social worker and foster carer throughout their care experience and beyond, when they move back into their families. I hope that the second will reduce the number of children coming into public care as their parents are relieved of the pressures of temporary accommodation, which is often overcrowded and long distant from the support of their relatives and community.
	In the interests of keeping within my time, I hope that on this occasion I may read from a script. I warmly welcome the prospect of many more homes and, in doing so, declare my interest as a landlord. The youth homelessness charities, Centrepoint and Foyer, point out that the lack of move-on accommodation prevents them settling significant numbers of their hostel residents. This means that the 16 year-old young black woman who finds herself in a wholly inappropriate bed-and-breakfast accommodation, lacking locks on the bedroom doors and shared with older men of whom she is afraid, is denied the support of a Centrepoint hostel because there is not the room. It means that the young black man who is ready for an apprenticeship in a carpentry shop is denied the support that Foyer could give him to make this happen because there is not the room. Barnardo's Families in Temporary Accommodation Project (FITA) points out that the level of homelessness compels families to accept damp, overcrowded, unhygienic, often privately rented accommodation which can be several bus journeys away from their relatives or communities and deepens the debilitating sense of isolation that such families can experience, especially those with one lone parent.
	Shortage of affordable housing erodes our efforts to recruit and retain social workers and teachers. Not so long ago I was speaking to the head of a primary school in Camden, north London, who was lamenting the loss of one of her best teachers because that teacher could not get on the housing ladder in London. Care leavers—young people who have been in public care—are deeply concerned at the lack of suitable accommodation for them. Foster parents can be discouraged from fostering because of the lack of space in their homes. Shortage of housing can cause the bitterest resentment against immigrants and the sharpest community divisions. I warmly welcome the prospect of 3 million new homes and congratulate the Government on bringing this forward.
	As regards the Children and Young Persons Bill, it is gratifying to see the Government produce further legislation specifically to meet the needs of children in public care. The very process of bringing forward legislation will prioritise these children on the agendas of schools and local authorities. There is very much to welcome in its specifics.
	I wish to consider the principles on which such a Bill should be based and, I trust, establish the matters on which we can agree. First, it is enormously wasteful of public money, and harmful to children, to neglect social services as we have done over so many years. If early intervention is our ambition, intervening when social workers are almost totally demoralised, when foster carers are impossibly difficult to find and when the most vulnerable children have been placed in residential care with the least well equipped and valued carers for many years, should never be repeated. I am deeply grateful to Her Majesty's Government for beginning to address this long neglect.
	No wonder the Government seem to have had so little return on their £1.9 billion per annum on children in care and their investment in social care training. Contrast this with reports from Ministers and Members of Parliament who have visited Denmark. What they see is a vastly higher quality of provision at a similar or lower cost. Instead of supporting foster carers, social workers and residential childcare workers to deliver excellent care, we have had to invest hugely in checks—we have a new regulatory body forthcoming—to prevent those carers doing harm to those they care for. We have been on the back foot when we should have been pushing forward. The best safeguard for children is an environment of overall excellence, as Sir William Utting, chairman of two reports on safeguarding children, put it. I hope that we can agree that this Bill can be only one of those several first steps that Her Majesty's Government have been taking. Sustained funding for social services must be secured, as so many of your Lordships stated this afternoon. I ask the Minister: are current arrangements right where elected councillors must make spending decisions knowing that their electorate prize good roads and efficient rubbish collection well above the invisible services of foster care and social workers? What steps is he taking to ensure that there is the long-term, consistent investment in the social services that is required? The noble Baroness, Lady Barker, and the right reverend Prelate the Bishop of Leicester referred to this.
	The second principle on which I hope that we can agree concerns the importance of stability to children in public care. In launching the Care Matters White Paper, the right honourable Beverley Hughes said, "Stability, stability, stability", indicating that this was the cornerstone of the Government's approach. I add to this the vital importance of each child having a long, stable relationship with a particular carer. All our experiences of our own families and all that modern neuroscience has taught us about the development of the child's brain indicate the imperative of a reliable relationship with a close, long-term, consistent carer—someone who takes a genuine interest, thinks about one when one is not there, remembers one's birthday, points out when one has overstepped the mark, someone to admire and to copy. Most importantly, one has to have experience of this reliable relationship if one is later to fall in love, have children and a family of one's own that does not simply repeat the horrors of previous generations. Here we are obliged to consider that most of these children have been let down by the adults they most loved and trusted many times and sometimes in the most horrible ways. Many of these children will be of the firm conviction that adults let one down and that being close to an adult can lead only to disappointment. They will therefore seek out and focus upon any indication—even the smallest unintended one—that they are unwanted. Hitherto, the care system, with many honourable exceptions, has done an effective job of confirming that conviction—that one should trust no one.
	The third related principle that flows from this is that social workers, foster carers and residential childcare workers must be allowed to bring the very highest level of consideration to the work they do in caring for these children. They have to be allowed the time to reflect and to be able to draw on the expertise of other carers as they manage and sustain their relationship with their children. Does the Minister agree that if we are consistently to maintain the trust of children and young people, those closest to them must have this opportunity for reflection? What is he doing to support such opportunities for reflection? The importance of this was very much highlighted in the Options for Excellence White Paper. The General Social Care Council strongly encourages the Government to implement early and fully the recommendations of that White Paper of October 2006. May I ask a related question? While we know how many placements of children with foster carers break down each year, do we have a reliable figure on how often children have a change of social worker during their time in care, at risk or in need? I think that the noble Lord, Lord Darzi, referred to such a figure. What is the Government's specific target or aspiration for the number of such changes in future?
	That principle of stability is strengthened by a number of measures in the Bill. Local authorities will be obliged to provide a range of suitable placements locally for children. Social workers will be obliged to visit children on a regular basis, including those in the criminal justice system. Young people in care will be encouraged to remain in care until the age of 18, and pilots will be undertaken to give young people a veto on leaving care before the age of 21. The latter could be especially useful for young people at university, as has been mentioned, who need accommodation during non-term times. All of the above, however, raise important questions about resources.
	Where are the foster carers to be found to achieve those aims? Vital to retaining the foster carers are the social workers who should support them. The Bill adds considerably to the burden of social workers. Where will the expert social workers be found to meet the need? I acknowledge the significant steps that the Government have taken in recruiting more social workers. Will an obligation to be commissioned locally, except in special circumstances, in some areas encourage the commissioning of poorer quality but more local placements? Will specialist children's homes be edged out by the insistence on commissioning within a local authority? Some 40 per cent of children coming into care currently do so at the ages of 10 to 15. By that age, a significant number of those will have had enough of families, or will not wish to replace their own family with another. To keep the right balance of residents in a children's home, there should at best be an aim for 80 per cent to 85 per cent of capacity, so there needs to be some slack in the system. Will the Bill ensure that there is the right supply of good quality residential care in future?
	Related to the above is the future of social work. I praise the Government again for the many helpful steps that they have taken to boost social work. The Opposition have recommended in their report on social work that there should be a chief social work officer. I hope that the Government will pay careful attention to that, especially as there is to be a new regulatory body and concern has already been expressed that the voice of social work may not be so prominent in it; my noble friend Lady Howarth referred to that.
	There is concern about the creation of independent social work practices. I know that the Government see virtue in that, as it may create institutions with a stronger independent focus on the needs of the child. However, I am concerned that this may be a distraction from the fundamentals of the problem that we are facing. I look forward to hearing the Minister's rationale.
	The final principle on which I hope we may agree is that young people in care need to feel that they can achieve. They need the qualifications to land work that they find rewarding, which meets their abilities and pays their rent. This has been spoken about already, and I warmly welcome what the Government are doing in terms of the education of young people in care.
	In conclusion, I warmly welcome the two Bills and the opportunity that they both offer to provide increased stability in the lives of our most vulnerable children, in their early family life, in public care, if they have to be taken into care, and in their transition from care. I look forward to working on this legislation.

Lord James of Blackheath: My Lords, the Benches here warmly welcome the appointment of the noble Lord, Lord Darzi. We welcome it so strongly that we would like to think that he can spend his entire time concentrating on the clinical and medical implications of the National Health Service without any distractions from the business around him of the national health in the wider context. At the moment, we find ourselves very confused as to the state of the National Health Service's finances, largely as a result of the not entirely helpful filing of the year-end accounts at the end of the past fiscal year. As it stands, they are showing a surplus of £515 million, which would be very welcome after a total expenditure of £391 billion in the past six years and aggregate over-runs of £1.419 billion in that time, all of which have been recovered by the Chancellor's golden rule of recovering against the following year.
	However, the £515 million does not quite look to be exactly what it represents itself as. When we go into it, we find that the whole NHS last year was subject to an acknowledged £450 million contingency, which was centrally imposed at the DoH level. The noble Lord, Lord Hunt of Kings Heath, emphasised that clearly to the House on the last occasion that he spoke to us on the forecast, when he was forecasting a £90 million to £115 million surplus for the year. That was very close to the end of the past fiscal year.
	In the remaining days that fell to expire before the end of the fiscal year, the figure has gone up from £115 million to £515 million, which represents a going rate of improvement at the EBITDAR level of about £6 billion, which would make it the most profitable enterprise ever in the history of this country. At the present level of enhancement, if the noble Lord, Lord Darzi, can continue that for another three weeks, he will have paid for the 2012 Olympics out of his own spare cash. That would be welcome to us all.
	However, that does have a slight credibility problem and one looks back at the numbers that have been filed to see if we can find out how good this £515 million is. We find that, in addition to the £450 million central contingency, something else was not declared to us—a further contingency that is not a contingency of £825 million. This is a strange fish indeed, unlike anything that I have seen before. The £825 million was apparently imposed after deducting the £450 million from the total central funding. It was decided by the Department of Health that a top slice should be imposed on the rest of the budget after the budgets had been allocated and compiled by all NHS trusts. It was decided that that figure of £825 million should be imposed wholly on primary care trusts, and it was taken from them and deposited with the strategic health authorities. This raises huge questions and, frankly, starts every nerve in my body going as a warning signal.
	First, where is this £825 million? What is it doing today? How did the primary care trusts manage to function with their budgets deprived of £825 million in the year? What cuts have been made? Apparently, they will get the money back in 2009, and, therefore, they will be without it for two years. They are short not only this year but next year already. If you add the £825 million to the £450 million, you come up with a total contingency of £1.275 billion. Deducting the £515 million from that figure—the surplus—implies that the National Heath Service has used by the end of the fiscal year £760 million more than the budgeted level of the entire trust structure of the NHS at the outset of the year. That sounds to me like a £760 million deficit masquerading as a £515 million surplus. I would seriously like a better explanation of those figures and how they work.
	Other questions accompany that. Is the £825 million real money or is it a balance-sheet adjustment? We would not know, because we have never been given a consolidated balance sheet for the National Health Service, which, again, I plead for us to have, backed with a source and application account. Then we might see this matter much more clearly. If the £825 million is real cash, has it been placed effectively on some form of bond or yield, because the interest on that in two years alone would buy at least one or two hospitals and goodness knows how many scanners? If it is on some form of deposit, if I was running the primary care trusts—God forbid—I would immediately go to the strategic health authority to obtain a letter on nice, government-headed paper saying that I owed them £825 million in two years. I would hare off to the nearest bit of the sub-prime banking market I could find, borrow the £825 million all over again and spend it, just to meet my targets for the year. If that has happened, that money is clearly not in the contingency. If it has not happened, is that money securely placed with a triple-A-rated bond yield for the two years to come and will there be money that can be directed back into some other asset?
	Meanwhile, what cuts have been made? We know of one big cut made last year, when 22,363 nurses were culled from the National Health Service. If you want a visual image, that is almost exactly the same as filling Lords cricket ground on a major test match day with nurses only and telling them at the end of the day to go home and never come back to work again. Thank goodness it was not Wembley—otherwise it would be 88,000. That is an awful lot of nurses to be going without. How does the system function without them?
	Looking at what is coming up, 50 hospitals are in development and production for the NHS in this country, with another 30 queuing for development behind them. Their aggregate cost is said to be £53 billion, with front-end loading on their financing. That would imply a minimum of £3 billion a year that would need to be funded out of the existing NHS budget for the best part of the next 30 years. Will that money be replaced with like-for-like funding from the Treasury, and, if so, is that another hit for taxpayers' pockets? Where will that money come from? Can an administrative burden be removed to cope with that? We do not seem to have a feel of where this is going in the long term. We deeply wish the noble Lord, Lord Darzi, to succeed in all his objectives, but all the factors that I have mentioned have a clinical impact because they will curtail the usefulness of what he can do, unless there is a financial structure within which he can operate.
	Finally, we understand that at the moment PFI subjects do not appear anywhere on balance sheets as future liabilities. That is beginning to be a real problem because at present PFI costs are reaching the point where they have virtually repaid the capital cost of the equipment and facilities that they purchased and now have to go on as an enormous revenue outflow on behalf of the NHS for years to come. We ought to know the impact of that. It is time that we had a consolidated balance sheet and source and application accounts to show that.
	I welcome the noble Lord, Lord Darzi, to his position, but I cannot imagine that he ever woke up one day and said, "My goodness me, I want to run the biggest business in Europe with all its financial issues". He probably woke up and said, "It would be a lovely idea to reform the whole National Health Service". We hope very much that he soon has the financial stability to enable him to do so.

Baroness Massey of Darwen: My Lords, I am dazzled and somewhat overwhelmed by the previous speech. I was pleased to see in the gracious Speech an emphasis on aspirations to give children the best possible start in life and on improving conditions for vulnerable children and young people, including those in care. I was uncertain about which debate to speak in. I wanted to address youth justice issues, but I am convinced that my noble friends Lord Adonis and Lord Darzi will subscribe to the concept that children, with their needs, come first, beyond any system in which they may find themselves. Much of what I want to say will be applicable to all vulnerable young people. I look forward to working on the Children and Young Persons Bill, which I hope will get to grips with a number of issues that will make a real difference to the lives of young people.
	Many in your Lordships' House have long been concerned for vulnerable young people; we have heard from some today. I declare an interest as the chair of the All-Party Group on Children, which has frequently expressed its concern for the education, health and well-being of vulnerable children and young people, who are too frequently not best served by public services. I also chair the National Treatment Agency for Substance Misuse, so I am very concerned about the impact of drugs and alcohol on offending behaviour.
	My starting points for action on children and young people are the United Nations Convention on the Rights of the Child, which makes the welfare of the child paramount; the National Service Framework for Children, Young People and Maternity Services; and the Children Act 2004, building on Every Child Matters, which states that good outcomes for children include being healthy, staying safe, enjoying and achieving, making a positive contribution and achieving economic well-being. Those should be aspirations for all children, including damaged children and those who offend—frequently the same group of children.
	I am aware that many good things have happened and that a health and social care strategy for young people in contact with the youth justice system is currently in preparation and will appear next year. Indeed, I was privileged to attend, earlier this week, a discussion day on that. At that seminar and from my reading and experience, several issues stand out as being in need of attention if we are to improve conditions for young people in the youth justice service, rehabilitate them and reduce offending. Very many organisations in the voluntary sector and the Children's Commissioner have expressed the view that damaged children should not be damaged further. While there are undoubtedly dedicated professionals working with children, often structures and systems militate against them. The report of the noble Lord, Lord Carlile, is certainly worth revisiting.
	I am aware of government action to lift children out of poverty, to increase the availability of child care, to introduce a national entitlement to free early years education, to raise standards in schools, to reduce teenage pregnancies and to reduce accidents involving children. All that is positive and to be commended, but challenges remain in both the short and the long terms. The intent of the noble Lord, Lord Darzi, to encourage healthcare that is fair, personalised, effective and safe must surely apply to all services, including those for young people who fall outside our mainstream systems. I find it encouraging that youth justice now comes under the brief of the Minister for Children, within the Department for Children, Schools and Families. Can the noble Lord, Lord Adonis, say how youth justice will be handled by the Children's Minister? What links are being made to other sections of government, the voluntary sector and the Youth Justice Board?
	The 2006 report from the Healthcare Commission and Her Majesty's Chief Inspector of Probation points out:
	"While it is true that support and services for young people who offend has improved significantly over the last three years, current levels of provision of healthcare for children and young people who offend, especially mental health services, are unsatisfactory".
	In addition, one study indicated that over a third of young people in custody have a reading age of seven or less, 45.4 per cent have substance misuse problems, and between 40 and 49 per cent have been in local authority care, which was referred to by the noble Lord, Lord Ramsbotham. The costs of not dealing well with young people in the youth justice system cannot be ignored. Indeed, the cost of putting so many people into custody in the first place cannot be ignored. A place in a young offender institution costs around £50,000 a year and in 2005-06 more than 212,000 disposals were given in the youth justice system with 85,467 new entrants to the system. Every year, 8,000 young people pass through the system. In September 2007, there were 3,095 under-18 year-olds locked up. England has one of the highest levels of incarceration of young people in Europe. In 2006, 76 per cent of young people released from custody reoffended within 12 months. The system simply is not working, and that is a tragedy that must be addressed.
	The standing conference on youth justice regrets the increase in the use of custody for children. Since 1992, custodial sentences have risen by nearly 90 per cent and the use of detention for children under the age of 15 has grown by 400 per cent, which is a shocking figure. The number of vulnerable children detained in youth offender institutions rose from 432 in 2002 to over 3,000 in 2004, and it continues to rise. There is a trend to increase the prosecution of young people, despite good evidence that prosecution tends to be of no use in preventing reoffending. The Youth Justice Board has expressed concern that the breach of ASBOs is impacting on child custody, and youth offending teams are concerned that they are rarely consulted about decisions on ASBOs.
	We need to prevent young people from getting into trouble in the first place. That is a difficult challenge, which may be affected favourably by government action to do more for youth. We then need to assess the needs of young people who come into contact with youth justice and try to supply interventions that will help to rehabilitate them rather than encourage reoffending. It is a retrograde step to seek to provide more correctional institutions rather than to set out to improve health and education services for offenders outside institutions or inside them, if that is what it comes to. It is also sad and counterproductive that we are increasingly tending to demonise and criminalise young people when other corrective measures would be more effective and appropriate. A punitive approach labels children early as miscreants and may well encourage bad behaviour rather than treat it.
	Let me now look at some of the areas that could be examined in order to tackle the problems with regard to young people's health in the youth justice system. Some of the comments made by the noble Lord, Lord Darzi, about children in care are also relevant to the welfare of young offenders; we may want to explore that later. As the noble Earl, Lord Howe, said, this depends on culture and people, not just systems and structures. The Let's Talk About It report, to which I referred, states that one of the most significant findings is a lack of strategic involvement in the healthcare of young offenders. There is no adequate engagement of healthcare professionals in 60 per cent of youth offending teams. The report recognises that that may be understandable, with changes in structures and competing agendas, but it is unsustainable, especially given that there is good practice in some areas of the country.
	In numerous reports over the past few years we have heard of failures to work across specialisms, but within health services for young people in trouble there must be, across mental health problems, drug and alcohol problems and physical health needs, adequate assessment of need and co-ordinated monitoring of what is being provided. Every primary care trust must have a representative on the youth offending team. I realise that multiple PCTs may serve a YOT area, which is a complication, but it is not insurmountable. Services need to be responsive to the needs of 16 to 17 year-olds, particularly as that age group is responsible for the majority of crimes committed by young people and for the more serious crimes.
	The joint inspection of youth offending teams in 2006-07 identified several areas that could be tackled—for example, case managers being untrained or unskilled in screening for physical health, poor communication between health professionals and case managers, and inadequate or non-existent service level agreements and protocols between YOTs and the various health providers. There was little evidence of systematic and formal evaluation of outcomes from interventions. One in six YOTs had no healthcare worker and a third of them had no mental health worker.
	Various government departments have been good at identifying the needs of young people and other client groups. We have got better at listening to clients, including children and young people, although I have not come across much evidence of consulting young people in trouble with the law. My plea for today is that we exercise more caution in punishing young people and that we focus more on their welfare. If young people do get into trouble—and some of them get into horrendous trouble—we should purposefully assess why they are in trouble and what their needs are, and deal with those needs rather than making assumptions, labelling and stigmatising. I hope that the two Ministers here today will take that on board and influence colleagues in other departments as well as in their own on some of the issues that I have raised today.
	I congratulate my noble friend Lord Darzi on his speech and look forward to my noble friend Lord Adonis responding to the debate—a gargantuan task. I look forward in particular to the new health and social care strategy for young people in contact with youth justice. I hope that it will dovetail with the Children and Young Persons Bill and that all this will benefit young lives on the ground.

Baroness Deech: My Lords, I join others in welcoming the opportunity that we have this afternoon to discuss health matters of such importance and to receive the assistance of the noble Lord, Lord Darzi, whose success your Lordships hope for.
	It has been commented that there is little new in the legislative proposals made in the gracious Speech. In a non-pejorative sense, this is true of the Human Fertilisation and Embryology Bill, as the ethical and legal principles that it embodies have been of exceptional interest to this House and to the public for nearly 30 years, since the birth of the first IVF baby, Louise Brown—a miracle achieved by British doctors.
	I declare my interest as the longest-serving chair of the Human Fertilisation and Embryology Authority—from 1994 to 2002. Noble Lords will understand if I go on to say that Britain is an acknowledged world leader in IVF, embryology and stem cell research. It is as advanced as the USA but more regulated, avoiding the excesses of freedom and restriction in the USA and in Europe. Progress in this country has been largely in tandem with public acceptability. Other countries have run into trouble: the US bans federally funded stem cell research while leaving basic IVF unregulated; Germany and Italy prohibit diagnoses and treatments that are taken for granted in the UK; and South Korea, an advanced nation, has suffered from fraud in its practices.
	It stands to reason that the benefits of the existing law should be continued. It has the virtues of great flexibility of definition, discretion lodged in the regulator and a cascade of detailed decision-making down to the clinics, patients and scientists, all within an acceptable legal framework. This has been achieved since 1991 by the Human Fertilisation and Embryology Act. When I was chair of the authority under that Act, I was often accused of playing God, to which I would answer that it was not the chair or the members of the authority who were playing God. The Act represented, and still represents, a democratic compromise between strongly held views in society. The authority works to reconcile, to explain and to point to a way forward, and it is accountable to the public.
	Our structure at the HFEA has been studied and emulated to a greater or lesser degree worldwide. It rests on the famous report authored by the noble Baroness, Lady Warnock, in 1984. The Warnock report remains the most constructive, pragmatic, ethical, deep and influential report of its kind in the world. It just goes to show how much you can achieve by putting a university philosopher in charge of building an element of government regulation—how much better than putting businesspeople in charge of university philosophy departments.
	The Bill that will come before your Lordships transfers into primary legislation certain issues that so far have been left to the regulator: rules about pre-implantation genetic diagnosis, sex selection and animal-human hybrid embryos. The pre-legislative scrutiny committee on the Bill was able to come to conclusions on those issues, but it also tended to agree that the more that could be left to the regulator, the less likely the new law is to be short-lived and subject to legal challenge. Having heard evidence from ethicists, the committee rejected the notion of a national ethical body alongside the regulator.
	The law already incorporates ethical principles that determine most matters and it is open to this House to consider the setting up of a parliamentary bioethical Select Committee. That would be difficult to achieve. How can one, in one committee, reconcile the opinions of those who would stop all embryo research and those who go along with the regulatory framework? There would certainly be fewer ethical concerns if IVF was generally available on the NHS and if there was no postcode lottery for the limited service that is available.
	I must return to ethical questions. There are risks in the proposed new law that worry me. The risk is of dehumanisation. I am concerned to see that the Government still want to remove from the law that clause that states that the doctor proposing to give IVF treatment should consider the welfare of the future baby, including the need for a father. I find it extraordinary that it should at this moment be seriously considered that this House make a statement that, in welfare, there is no need for a father. This is a moment when we know from research in this country and abroad that a special contribution is made by fathers to the raising of their children, which is not replicated by the contribution made by mothers. We know that it is said that children lack male role models and that some of the violence and disorder in society is created by the lack of fathers.
	There is a further risk. In reproduction in general, the role of men has been downplayed. In recent years, women have fought very hard to have their femininity and their wishes recognised in the field of reproduction. Every woman is a worthwhile person, whether or not she has children. She is regarded as in control of her body and has fought to be respected. But what about men? They are in danger in this field of being reduced to a sort of genetic contributor and nothing more. It would be deeply regrettable if the express reference to their role as parents were undermined or removed. Women have won the battle to be respected as parents and it is now, for once, time to worry about men as well.
	There is another risk. I find it strange—I think that in 100 years it will be regarded as even more odd—that the law might provide that a birth certificate will show two women as the parents of the child. One understands that that comes from a desire not to discriminate, but at the same time we all respect the truth, and to have a birth certificate listing two women as parents is an odd way of pursuing the truth. The pre-legislative scrutiny committee was very anxious to ensure that donor-conceived children should be given every opportunity to discover the truth about their origins, but it believed that children need two parents, preferably including a father. The Bill will promote the truth about origins, so why should it also provide for birth certificates naming two parents of the same sex? The Bill will ensure non-discrimination between family units and persons, at the expense, it could be argued, of the welfare of the child. After all, British law still rightly discriminates against underage, polygamous and incestuous unions, so why should the family welfare of a child not be considered before the mother undergoes IVF?
	Current government and judicial policy is that fathers have a vital role to play. We should not be afraid of being labelled politically incorrect in standing up for the welfare of the child, as we best understand it in current conditions, even though this House should be assured that the existing requirement to consider the welfare of the child, including the presence of a father, has not been, and will continue not to be, a barrier to treatment.
	A sensible Bill would retain the HFEA, make reforms to the Human Tissue Authority and give broader discretion to the HFEA in future research involving hybrid embryos and genetic diagnosis. It would remove the excessive confidentiality provisions that block follow-up research on IVF children and would give the regulator greater powers over the charges and menu of treatments currently presented by private IVF work as well as greater enforcement powers. It should be minimalist, because what we already have is pretty good. Unfortunately, those who want to change abortion law and unsettle the consensus that has prevailed over the status of the embryo will look for opportunities to hijack the proposals.
	This House should remember that ethical principles regarding human fertilisation have already been worked out. One such principle is the assurance of human dignity, worth and autonomy. Everyone is dignified, and everyone should have the right to consent to the use of their bodies and not to be treated as a bank of spare parts. The welfare of the potential child must be considered and safety must be given great weight in new treatments. All of us who remember the Thalidomide situation so many years ago will understand the tremor of considering new and untested treatments, even in the light of the best possible scientific advice. Another ethical principle is respect for the status of the embryo. A new principle is that the saving of life is an acceptable use to which new advances in embryology may be put. However, let us not think that reaching ethical consensus is an easy matter. We are polarised.
	I close on a more light-hearted note. Your Lordships will know that every religion has different views about the viability of foetuses and embryos and how deserving they are of protection. I am often asked what the Jewish view is of the viability of the foetus, to which I say, "It is not viable until it has graduated from medical school". I look forward to further discussion of this important Bill and to improvements to the nation's health.

Baroness Cumberlege: My Lords, I congratulate the noble Lord, Lord Darzi, on his speech. I am delighted to see him here at the Dispatch Box. Before I address the issues in the Queen's Speech, I shall mention his interim report, Our NHS, Our Future, to which he referred in his opening speech today. It is said that this report had to be hurried. None the less, it is very interesting, because it comes from a surgeon. The noble Lord's skill is indisputable. He leads in his surgical field, and his reputation is international. The opening words of his report are:
	"I'm a doctor not a politician".
	Your Lordships must be sympathetic. After all, doctors and surgeons must be at the top of the popularity table and we politicians are, I fear, near the bottom.
	The traditions of this land require every Minister to be answerable to Parliament, and I find myself strangely at one with the right honourable Prime Minister, who, through the Queen's Speech, said:
	"My Government is committed to openness and accountability, and to a strong Parliament able to hold the Government properly to account".—[Official Report, 6/11/07; col. 3.]
	The noble Lord, Lord Darzi, has for better or worse allowed himself to be appointed a Minister of the Crown, and therefore he is accountable to Parliament. In this House that is onerous—I know, I did the job for five years.
	In your Lordships' House the Minister is on his own, a solitary figure, whereas in another place there are cohorts—well, five—each with a portfolio of special interests. That luxury does not extend here. The Minister has to cover every aspect of health in every corner of England. I have no doubt that he can assimilate all the information very quickly while constantly checking on visits nationwide. Trying to manage a service that ultimately employs a staff of 1.3 million while attempting to meet the aspirations of the British public is taxing, in both senses of the word. That is especially true in an area that is so politically sensitive. Scarcely for a moment is the NHS out of the headlines. As a surgeon, the Minister may not wish to concern himself with the question so frequently asked within the service and outside: "Where has all the money gone?". That is a harsh political question for the Government—a Government whom he has chosen to join.
	In his opening statement, the Minister spoke about his passion for quality. That message is well known to this House and the NHS. The noble Baroness, Lady Jay of Paddington, who was the Minister of State for Health in September 1997, put out a press release with the headline:
	"High-quality not 'bean counting' to be central NHS priority".
	She went on to say:
	"Too often in the past the emphasis has been on service activity and on a narrow definition of efficiency measurements: quantity, not quality. Managers and health care workers have all been asked—often against their own better judgement—to concentrate on targets like patient throughput and bottom line accountancy rather than measuring success by the quality of what they are offering".
	The noble Lord, Lord Darzi, stated in his report 10 years later:
	Patients have told me that they still sometimes feel like a number rather than a person",
	and later,
	"targets ... [are ] not always the answer and sometimes they can seem perverse".
	Although I have to say full marks for honesty, this Government are extremely slow learners. Having negotiated a fairytale contract for GPs, the Government are now having to entice them back to the awful grind. This acknowledges that illness does not strike in the 40 or 50 hours the practice may be open on five days a week but can occur in any one of the 1,268 hours in the week when the GP should be there as the lead health professional.
	The Minister endorses the idea of super-clinics—certainly an idea for fierce political debate if only because it is highly contentious and, according to the BMA, probably flawed. Why not build on the network of existing community hospitals rather than close them? Why close so many maternity units when even Ministers are marching in the streets to save them? Saving them, from themselves. I do not want to discuss these issues now but I remind the Minister that these are highly charged political questions that must be answered, in almost all cases, by him. Why? Because he is party, with his fellow Ministers in the department, to making these policy decisions.
	In the forthcoming parliamentary year we look forward to two major health Bills. The first, likely to start in this House, is the human fertilisation and embryos Bill which was published in draft form earlier this year. I agree with the noble Lord, Lord Harries of Pentregarth, that that is a very good process to follow. However, among other things, the Bill will contentiously remove references to the need for a father, as the noble Baroness, Lady Deech, said, and also recognise same-sex couples as the legal parents of children conceived through the use of donated sperm, eggs or embryos. I can see many hours of debate with contributions from those with great expertise, including the noble Baroness, Lady Deech. I am delighted that the Minister will be taking this Bill through your Lordships' House with, I am sure, huge clarity and skill.
	What concerns me is the second Bill, the Health and Social Care Bill, which has been dubbed the "medical professions shake-up". This could be equally contentious, with the big health battalions scrutinising every word. Apart from amalgamating two major commissions and part of a third, the new Care Quality Commission will have tougher powers and will allow a civil rather than a criminal standard of proof. There will be a new independent adjudicator to review decisions taken by the regulators. All healthcare organisations will have to appoint a responsible officer who will work with the General Medical Council to,
	"identify and handle cases of poor professional performance by doctors".
	Having spent a year leading a working party on medical professionalism for the Royal College of Physicians and a second year selling it through road shows to the profession, I know how fragile professionalism can be. The Bill must do nothing to jeopardise, but rather to strengthen, the trust that the public have in doctors. As I understand it, this challenging Bill will not be taken through by your Lordships' accountable Minister, as he is perceived to have a conflict of interest; and here is the rub. It would be a terrible loss to surgery if the Minister gave up his practice, but if he is to be effective as a Minister—a top-flight politician effectively answering to the people through Parliament—surely he must agree that he has accepted a post as a politician under our constitution. He is a Minister of the Crown in a Labour Government, a Government who have more than doubled the NHS budget, reduced output per employee, introduced real fear in patients going into hospital when hospital-acquired infections kill thousands, and made an incredible mess of junior doctors' employment. There is much political work on his plate.
	In conclusion, I am sure that the whole House wishes the noble Lord, Lord Darzi, every success, as do I. But it is fair to say that we in your Lordships' House have every right under the constitution to expect the Minister to take major Bills through this House and to attend when required. It is the duty of the Minister—crudely, it is part of the job—to be available, so that he can be called to account for his Government's policy. I appreciate and have great sympathy that the Minister has a serious dilemma, and a choice that he alone can make.

Baroness Warnock: My Lords, I return to the subject of education and confine myself to a few points on that aspect of the gracious Speech. I congratulate the Government on undertaking to provide new rights for adults to acquire skills and training, a subject on which many of your Lordships feel strongly. However, the proposal on keeping young people in education or training until they are 18—the only other specific undertaking in the gracious Speech—seems more dubious. I share the anxieties that were powerfully expressed earlier by the noble Lord, Lord Pilkington. It seems to me that the Government are starting at the wrong end.
	In his opening speech the Minister said that there would be no compulsion except in the case of young people who did not recognise the benefits of participation in the scheme. I am certain that there will be many such young people, for the good reason that they have come through their entire time in the school system unable to read or spell or perhaps to perform the simplest calculation. After all, even for vocational education you need to be able to read. Some of the non-participants may already be in prison, where their chances of education are pitiably low in any case.
	Many of these young people have the disability, of varying severity, broadly known as dyslexia. Here I must declare an interest as president of the British Dyslexia Association. The truth about dyslexia is that it is a specific learning difficulty that can be identified in the first year at primary school, and the probability of dyslexia can be identified even before then, in the reception class. It is also known that early intervention is both possible and essential if the child suffering from it is to acquire the strategies needed to overcome his disability. But it is also known that teaching these strategies is a job for teachers with specific training in teaching dyslexic children—and, with much more difficulty, teaching dyslexic adults.
	Severely dyslexic children are often very bright and competent. If properly taught, they can excel academically. They can be taught how to read music and may do very well at it; the same goes for mathematics. But left without specialist teaching, they will never fulfil their potential, an aspiration unsurprisingly mentioned in the gracious Speech. As well as, or indeed perhaps instead of, concentrating on young people who have already failed, the Government ought to give an undertaking that, by 2012, every child should have access from the very beginning of their education to a specialist teacher if that is needed. This is a matter of the greatest importance and urgency.
	This means that every teacher should be trained in the course of their initial teacher training to identify the signs of dyslexia. However, many of us have experience of how difficult it is to persuade those responsible for initial teacher training to add new components to the curriculum. However, that is vital. If a child has been identified as at risk of developing dyslexia, or as already dyslexic, he can be handed over to a specialist to be taught for at least one hour a week, and a specialist is what is needed. It is literally worse than useless for an untrained classroom assistant to try to help a dyslexic child who is in difficulties. It may do more harm than good. Many schools now claim that they are "supporting" a child who has difficulties simply on the grounds that he has access to a classroom assistant. That is not enough and may make things worse as the years go by. The question of so-called support in schools, not in amount but in quality, must be addressed by the Government as part of their policy of inclusive education. If a child is given inadequate support, inappropriate support or ignorant support, his confidence, already low, will gradually fall even further.
	The tragedy in all this, and it is a tragedy, is that we know that early diagnosis and proper teaching can work. There are numbers of anecdotes of severely dyslexic people who succeed academically and otherwise as the result of proper teaching. The proof of this knowledge, sadly, is in independent schools. Nowhere is there such a huge gap between independent and maintained schools as in their provision to allow pupils access to specialist teachers. Attitudes have changed enormously over the past 20 years or so, and now the well known public schools—including the 25 schools comprising the Girls' Day School Trust—and nearly every private preparatory school, all of which are independent and very expensive, have at least one specialist teacher on staff either full time or for a few days a week.
	At the beginning of the debate the Minister indicated that the gap between academic and vocational education was to be narrowed, but surely we should be aiming to narrow the gap between independent and state education as well. That must be an aspiration of this or any other Government.

Baroness McIntosh of Hudnall: My Lords, the gracious Speech offers a rich mix of opportunities for comment and it was quite hard to decide where to jump in, an experience which a number of noble Lords have had. I might have chosen the Climate Change Bill, which, like the noble Baroness, Lady Barker, I welcome. However, it still fails, in my view, to take a sufficiently urgent view of the threats we face, particularly from the growth of the aviation industry. But it is the wrong day to talk about that or about the challenges in balancing national security against the preservation of civil liberties, although I hope that at least some of your Lordships saw the admirable drama "Britz", broadcast by Channel 4 last week, which gave considerable food for thought on this subject. Although I must not mention the proposed changes in the planning system, I am assuming that at the appropriate time other noble Lords will encourage the Government not to allow local opinion to be overridden in the drive for infrastructure growth.
	Today, however, is a good day to talk about young people. That has been shown by the many wonderful speeches we have heard, particularly by the moving contributions of several noble Lords about the needs of looked-after children. I want to talk about how we can help them to make the most of education and training and how they can link their skills and enthusiasm to the world of work. In this connection, I want to make particular reference to the Make Your Mark campaign and to its annual enterprise week, and to mention the role that the arts can play in education, as the noble Lord, Lord Ramsbotham, did earlier.
	Quoting from its own publicity, Make Your Mark is,
	"the national campaign to create an enterprise culture among young people in the UK".
	It was founded by the British Chambers of Commerce, the CBI, the Federation of Small Businesses and the Institute of Directors and is principally funded by the department we must now call BERR. It is supported by a wide range of organisations from the business community, education and the voluntary sector and has attracted significant corporate and media support for specific elements of its campaign such as "Make Your Mark in Fashion", which has just launched with a nationwide competition for young people to create a new range for an established sustainable fashion label. Nine leading sustainable fashion businesses are partnering Make Your Mark in this competition. I should at this point own up to a special interest because my son is part of the team running the campaign. I wonder whether the "Pink and Powerful" day in Liverpool, which was mentioned by my noble friend Lady Morgan will be joining in. I hope so.
	Make Your Mark's best known activity is enterprise week, which this year is taking place next week from 12 to 18 November. It aims to be a national celebration of enterprise, inspiring young people to turn their ideas into reality. Last year there were 3,184 events organised by 1,410 organisations and this year looks set to be just as successful. All this energy is directed towards enthusing young people about the possibilities of developing their own business ideas because, as Make Your Mark says,
	"having a can-do attitude and the capacity to spot opportunities and implement ideas offers very powerful benefits to the individual...There are also huge potential benefits to the UK from a more enterprising culture".
	The Government's Household Survey of Entrepreneurship published by the DTI, when it still existed, in 2006 reported a growth of 22 per cent between 2003-06 in the numbers of 16-24 year-olds thinking of starting a business compared with a growth of only 3 per cent for all ages combined. We need to make sure that we are providing the right educational environment for all this potential enterprise to flourish.
	The new Education and Skills Bill will raise the age for compulsory participation in education first to 17 and then to 18. I support this intention. The Bill will provide for young people to continue their education post-16 in a number of different ways, including full-time school or college, work-based learning and part-time education or training if they are employed, self-employed or volunteering. This range of options recognises the many different ways in which people learn. An even higher degree of co-operation between education and training providers, local authorities, parents and students will be required than we are able to achieve at the moment, but flexibility and diversity in provision are vital to give everyone a better toolkit for dealing with the increasingly unpredictable world into which they will be moving as adults. More people will have to be enterprising and ambitious on their own behalf rather than relying on old models of employment.
	The critical thing, however, must be the quality of education and training on offer. What work is being done, and what resources are being made available, to ensure that we can consistently deliver the highest standards in what is offered to young people in future? I noted the remarks of my noble friend Lord Soley on, among other things, personalising the provision of education services. That is so we can minimise the risk of developing a new cohort of educational refuseniks needing to be managed by coercion and sanction. I draw attention to the remarks of the noble Lord, Lord Ramsbotham, on the assessment of people at different stages in education and how important it is that we know what people can do rather than asserting what they should do.
	I suspect that success will depend upon the contribution of a wide variety of organisations, of which Make Your Mark is obviously one, but I remind my noble friend the Minister of the importance of the arts in developing the capacity of children and young people to learn effectively. I hope he will ensure that the valuable support of his former department, the DfES, for the excellent work being done by, for instance, the Roundhouse in north London, of which I am a trustee, does not diminish under the new departmental arrangements. Its programmes are designed to engage young people for whom conventional educational models do not work so well—and there are many of those, as the noble Baroness, Lady Warnock, pointed out—and have already attracted approximately 8,000 participants from the 16-plus age group since the Roundhouse reopened just over a year ago.
	I hope the Government will continue to invest in creativity and imagination throughout the educational system because children who are encouraged from the start to think for themselves, to express themselves through music, sport or drama and thus to learn to communicate—again I refer to the remarks of the noble Lord, Lord Ramsbotham, on the subject—and discover in these ways where their aptitudes and enthusiasms lie will have a better chance of taking advantage of the opportunities envisaged by the Bill. Enterprise, ambition and a willingness to learn are hard to insist upon between 16 and 19 if they have not been instilled much earlier.

Lord Dearing: My Lords, I thank the noble Lord, Lord Darzi, for his lucid exposition of the parts of the gracious Speech referring to health, social matters and education. We have a great task facing us, as has been mentioned. I recall that when I was chairman of the Post Office there were two jobs I felt were well beyond me. One was trying to run British Rail and the other was running the health service. Thank God no one asked me. The Minister has the great advantage of knowing what he is doing.
	I shall move on. On Tuesday, the noble Lord, Lord Strathclyde, referring to the challenging problem facing the ninth husband of Zsa Zsa Gabor, said that he knew what to do but his problem was how to make it interesting. I reflected on the education Bill facing us, and thought that there is many a teacher who may be wondering how to make continuation of education interesting for some likely lads and lasses until they are 18.
	For 140 years, we have been searching for a solution to the problem of the serious skills deficit of this country. Like that ninth husband, we have not found a way—and I must choose my words carefully—of matching the challenge, which was first addressed by a parliamentary Select Committee as long ago as 1868. In the century that followed, no fewer than 20 other committees addressed the problem of our shortage of skills. In the 40 years that have followed that century we have still been searching. During my tenure at the School Curriculum and Assessment Authority, I was invited to make a contribution. I was lucky to be able to introduce the GNVQ into key stage 4, which increased the number of children engaging effectively in education. However, it was a very modest contribution, and I recognise the progress that the Government have made in this during their years in office, but we have been playing a game of "catch up and keep up" rather than leading the race.
	I welcome the four measures taken by the Government that come to mind. One is the introduction of the new specialist diplomas. The second is their unambiguous "yes" in their response, signed by no fewer than six Ministers, to the Leitch report, which said that by 2020 more than 40 per cent of the population between the age of 19 and retirement age will need to be up to level 4 and beyond. Thirdly, we have the proposals on the extension of the leaving learning age—we must not call it the leaving school age—and, fourthly, we have the new Children and Young Persons Bill. All those measures are a coherent response to the need to lift our effective investment in young and older people—as has been said, we must not forget that 70 per cent of those at level 4 are already at work.
	I welcome all that, subject to two comments—although, having heard the noble Lord speak about prisons, I shall raise that to three. My first point is that 40 per cent of people reaching level 4 and beyond is not enough. As leaders in the world economy, Japan and the United States have already achieved that. We are talking about where we will be in 2020 and, unambiguously, we must have reached a figure of 45 per cent. Secondly, as much of the lift from the present 29 per cent to 40 per cent—or, as I said it should be, 45 per cent—has to be achieved by people who are already at work, we must be concerned about our capability to engage with those people.
	I have one question on which I should like to ask the Government to reflect again: will their support for these people be adequate? Of course, we do not want the Government to substitute Exchequer money for the billions of pounds that employers rightly put into training. They cannot afford to do that, but plenty of others—for example, in many small and medium-sized enterprises—are not looking into the long term and are not investing in their people. Obviously, quite a few employers worry about making such investment because, if they uplift their skills, they are in danger of losing some of their best people. There are also people who are just trying to get on to the housing ladder and are skint, and then there are carers and women returning to work who are not in comfortable circumstances. If we want to lift investment in these people, we have to help them more.
	My third point, raised by my noble friend Lord Ramsbotham, is concern about young people in prison, although I would extend that to all people in prison. What an awful waste it is to pay £40,000 a year to keep a person there with the high risk that he or she will return. It would make good personal and national economic sense to enable these people, on a scale that we have not attempted in the past, to engage successfully in training. I do not know whether there have been any studies into this but perhaps we should also think about the special problems facing the children of long-term prisoners.
	I want to make two points this afternoon. First, to address the skills agenda and to make more young people want to continue in learning—which I believe is an essential element in a successful policy to extend the learning age to 18, for coercion on any scale simply will not work—we have to rethink the comprehensive model of education for 14 to 18 year-olds. It is not the best model for delivering the Government's agenda for world-class skills on the scale required. We need to be able to offer young people the opportunity at age 14 to go to a college of technology in our cities and big towns specifically to develop skills preparatory to an apprenticeship or to pursue specialised diplomas that require specialist equipment. The noble Lord, Lord Darzi, referred to a record number of 250,000 people being in apprenticeships; the Leitch report refers to our needing 500,000. The task is therefore huge.
	If we are going to extend the learning age to 18, as proposed, we will inevitably need new buildings. We shall need to enlarge our cadre of teachers skilled in teaching the skills that industry and commerce need. We would be seen to be taking skills very seriously if 14, 15, 16 and 17 year-olds, rather than having to move from one comprehensive school to another or to an FE college to do their specialist work, were able to go to purpose-built colleges of technology, continually equipped with the latest tackle needed to develop their skills. We would show how much we cared. The Government's commitment to rebuilding, or a major refurbishment of, all secondary schools provides us with an opportunity to consider how we can, through technology colleges, provide what we required to avoid continuing to play the catch-up game for another century, which we cannot afford. The only asset that this country has is its skilled and well educated people—its effective members of the community. We have made a commitment to rescuing ourselves from 140 years of catch-up and we should respond to that by being ready to look at whether the comprehensive model is the best fitted to deliver this agenda for 14 to 18 year-olds.
	My second point echoes points already made. For the policy of continuing in learning to work, it must be in place next September to respond to the needs of 12 year-olds who have fallen behind and who will be the first to come to secondary schools expecting to stay in education, learning and skills development till 18. Otherwise, those people will regress in relation to their peers. It is a major challenge. Unless we succeed in that, the policy of continuing in learning till 18 will not work, because too many young people will not want to stay on after 16. After all, we have a big-enough problem already with 14, 15 and 16 year-olds who choose not to go to school, and who, at 16, employers will welcome as employees or trainees on their premises.
	The Prime Minister referred in his speech to the Labour Party conference to a moral duty to help those who come from disadvantaged backgrounds. We have a moral duty to respond to the needs of those young people. It is a social imperative that we do not continue to have 200,000 young who are in neither employment, nor education, nor training. This battle needs to be fought and won initially at the primary and pre-primary level. I referred to those coming forward at 12 only because they are 12 already and we have to do something about them now, this September. The battle has to be won at every step of the way, including primary. I rejoice in what the Government are doing about extending this pre-school stage to 15 hours a week. It will cost money, but it will be worth it. The Government are going the right way—but what we have to do, having got the right policies, is to have the right instruments to deliver them.

Baroness Sharp of Guildford: My Lords, this has been a long but very interesting and diverse debate. We began with an extremely coherent and full statement from the noble Lord, Lord Darzi, covering the full ground of the Bills mentioned in the gracious Speech. Like the noble Lord, Lord Warner, I welcome the fact that on this occasion we are considering the public services of heath, social care and education in the same debate. I have participated in too many debates on the gracious Speech in which I have been speaking on education alongside environment and agriculture, and it is a great joy to be speaking as part of the public sector debate.
	I shall not address the specific health Bills that my noble friend Lady Barker addressed in her opening remarks. However, common themes on these public services come through our debates. In all of them, the Government aspire to provide the best quality service for everyone and are faced in all of them by considerable inequalities, both in the provision of service and in the outcome of that provision at present. They are anxious to try to even out those outcomes. Many of those inequalities are linked to social class—which picks up a point that the noble Baroness, Lady Morgan, mentioned. In all they are trying to do, the Government are trying to deliver high-quality services, so that everyone can fulfil their potential and not be handicapped by the old Beveridge giant evils of ill-health, poverty and ignorance.
	Three interesting themes came through from the debate. The first was resources. The right reverend prelates the Bishop of Leicester and the Bishop of Ripon and Leeds, mentioned it, as did the noble Baronesses, Lady Howarth and Lady Murphy, who made the point that without resources we cannot deliver on our aspirations. We need money to deliver the programmes; not just money that is guaranteed for two years, but money that helps us to provide these services sustainably, over a period of years.
	One Bill that falls within the education remit is the one for reclaiming unused bank balances that were to be used for the provision of youth services. It is important to remember that it is not just, as with the National Lottery, a matter of providing capital funding to provide new youth clubs. It is a question of providing the continuing sustainable resources that enable those local authorities that have the duty to provide youth services to continue to provide those services year-in and year-out. It is because we have not been providing those services year-in and year-out that we are confronted by something of a crisis in this area. Resources must be provided over a long period. In our debates today, it has come through particularly in remarks on the Children and Young Persons Bill that we look to local authorities to carry through the reforms in relation to looked-after children. Those responsibilities should be delegated to the local authorities, but they must have the resources to be able to carry through the duties imposed on them. So resources constitute one theme that has come through.
	A second theme that I think has come through is implementation. The noble Lord, Lord Low, the noble Baronesses, Lady Young, Lady Howarth and Lady Murphy, mentioned this, as did the noble Earl, Lord Howe, in his opening remarks. If we are to carry through these programmes, we need competent people who must be trained—how foolish it is to take money from training budgets at a time when we desperately need to train more people—but above all people who are very well motivated. If people are to feel a sense of involvement with a service in order to implement it, they must feel a sense of ownership of it. It is vital that we motivate staff well. You have only to look at the fiasco of the medical training budget to realise what a very bad influence that was and what bad motivation it provided, so implementation and training competent management are vital. Therefore, the third theme that comes through is that of involvement and ownership. There are two senses in which this is important. One was picked up by the noble Lord, Lord Soley, when he talked about personalisation. It is vital that the services that we provide meet the needs of the individual child, the individual patient or the individual looked-after child. We need to personalise the services that are given to those people, which is expensive.
	I pick up the final point made by the noble Lord, Lord Dearing. We know that most teachers can identify children at ages six and seven who are likely to experience difficulties reading by the age of 11. We also know that if you get in there early and work with them at ages six and seven and give them personalised tuition at that point, whether it be phonics or just reading and reading recovery—it is a combination of everything and different kids respond to different methods—those children will be reading when they go through to secondary school aged 11. If they can read when they go through to secondary school aged 11, it is much more likely that they will not drop out of secondary school. A reading recovery programme costs £2,000 a year per child at age six. How much more valuable it is to put in that £2,000 per child at age six than—as the noble Lord, Lord Ramsbotham, mentioned—£40,000 per young person at age 16 or 17. Therefore, you should personalise services, get in there early and make sure that you provide the services that are needed.
	Here I put in a plea for therapeutic services, which are vital. Many looked-after children have psychological and emotional needs. It is vital that we recognise this and provide for these needs as well as for their straight healthcare or reading needs. As I say, we need to get in there early and personalise services. The noble Baroness, Lady Murphy, referred to localisation and making sure that Whitehall does not run everything. Whitehall does not know best for everybody and there are dangers in imposing top-down initiatives rather than pushing decisions down to the local level. Time and again these Benches have stressed the importance of making accountability local and not national.
	Thinking about top-down initiatives, I confess that I worry about the Education and Skills Bill. As the noble Lord, Lord Dearing, explained, the Government have been confronted by a pretty intractable problem. For all the money that has been pumped into the education budget, we have not been able to shift the participation of 16 and 17 year-olds as we would have wished. Above all, there is the problem of the 10 per cent who are not in education, employment or training. They oscillate between unemployment and short-term jobs for which they are paid at the minimum wage. They never acquire any qualifications, and they will probably go through life unemployed for most of the time. They are also much more likely to get involved in criminal activity. It has been an extraordinarily intractable problem.
	The Government have a top-down answer. They say, "We have tried hard, and we have spent money on the education system for the past 10 years, and they are still not there. We are going to pass a law that says that they have got to be there. If they do not come, we will give them ASBOs and fine them or their parents". That is top-down. To do the Government justice, they are not going to do that until 2015. Surely the answer is that those young people are not reading, so we have to put resources into making sure that they pass into secondary school.
	Moreover, for the past 25 years we have had a curriculum in our secondary schools that has turned off 50 per cent of our young people. The Government are introducing a new curriculum—an important curriculum—in the new diplomas, but we do not yet know whether it is going to work. It has not been piloted. They are rolling out five of those diplomas next year. I am worried that the schools are not ready. The noble Lord, Lord Dearing, made the point that if they are to deliver the diplomas properly, they must have specialist resources. Many schools do not have those specialist resources, let alone specialist teachers. Yes, they will work in consortia, and they will work with colleges, and many colleges will have those resources. The Increased Flexibility for 14 to 16 year-olds Programme that has already been introduced has shown that 14 year-olds benefit from such vocational initiatives.
	I admit that I personally have a great deal of sympathy with what the noble Lord, Lord Dearing, has been saying. It surely would be far better if we had dedicated facilities for these young people. The 14 and 15 year-olds, who often have the least motivation to go to school, will be wandering around the town from one school to another to study one subject here and another subject there. That is not the most suitable thing. Let us have dedicated technical institutes or technical high schools—which is very close to what the noble Lord, Lord Pilkington, was asking for—where, instead of being selected, children at age 14 can opt to go.
	Let us not have, as with the diplomas, two channels of training which cannot mix and match. As the noble Lord, Lord Adonis, knows, this has been a constant criticism of the way in which the Government have introduced the diplomas. There is no mixing and matching; if you opt for a diploma line you go for a diploma, and if you fail that diploma you will fail everything. You do not get O-level Maths and English if you do a diploma; you perhaps get the equivalent thereof. But what if you pass that bit and fail the rest of it? There are some real difficulties with the diplomas as they are. We want a technical or vocational curriculum to be offered, with specialist subjects. I have a great deal of sympathy with the solution suggested by the noble Lord, Lord Dearing; indeed, he and I have sat and talked about it outside on various occasions.
	I have doubts about the Education and Skills Bill being too top-down. The other doubt that I have about it, which is picked up by the Apprenticeship Reform Bill, is whether employers will really deliver. For 148 years, as the noble Lord, Lord Dearing, said, we have looked to employers to deliver on apprenticeships. Time and time again, they have not done that and they have not delivered on training. Are they going to respond to the skills pledge of the noble Lord, Lord Leitch? We do not have many more firms signed up. Behind the Apprenticeship Reform Bill is the threat, perhaps, of compulsion later—of some form of levy grant system. Maybe we should have that. Yes, we want apprenticeships, but we want them properly and coherently developed. At the moment there is far too much variation from one area to another on how many years people have to study for apprenticeships and what level they have to reach. I also warn noble Lords that far too many of those in modern apprenticeships are reaching only level 2, not the full level 3.
	Given the time, I will not say anything further about either the Sale of Student Loans Bill—although I have some reservations about it—or the Children and Young Persons Bill. My noble friend Lady Walmsley, who cannot be here today, spoke at some length yesterday. That is on the record, in Hansard.
	I return to the three themes that I picked up, because they are important. We must have long-term resources to sustain the services we need. We need good people who are well trained to implement those services, who are well motivated and who can act as champions for what we want. Lastly, we want personalisation and localisation. All are vital components of a successful policy.

Baroness Morris of Bolton: My Lords, I am delighted to have the opportunity to respond on behalf of my party to this key area of the humble Address. We have been treated to a wide-ranging, expert and thoughtful debate.
	We had a masterful exposé of smoke-and-mirrors accounting from my noble friend Lord James of Blackheath, a robust defence of the Conservative stewardship of the health service from my noble friend Lord Fowler, along with an incisive analysis of the crisis in HIV/AIDS. My noble friend Lord Colwyn pointed out in a measured way the problems facing dentists and I would hope that the Government would take up his offer of speaking to the profession. I had a wonderful vision of the noble Baronesses, Lady Emerton and Lady Murphy, deep sweeping and deep cleaning hospitals. It would be a brave bug that stood in their way or, indeed, a brave Minister.
	The noble Lord, Lord Soley, made a good pitch to appear on "Thought for the day". He could advocate his reasons why we should not be a "walk on by" society—a theme that I wholeheartedly endorse. The noble Baroness, Lady Finlay of Llandaff, highlighted the importance of flexible working to help women's progress in medicine. As a dyslexic, I have enormous sympathy with the views expressed by the noble Baroness, Lady Warnock.
	In the past six hours, we have had passionate and powerful speeches—all sprinkled with a good deal of common sense. I would love to mention every contribution because each deserves to be mentioned, but I fear that I will be foiled by the constraints of time. My noble friend Lord Howe set out the challenges we face in health and adult social care and how targets distort services. He explained why we feel that the Government's Health and Social Care Bill falls a good deal short of the rhetoric of setting the NHS free from meddling politicians and putting power in the hands of patients.
	My noble friend also spoke in his customary exemplary fashion and with sensitivity on some of the more controversial and difficult issues that will face us in the Human Fertilisation and Embryology Bill. Inevitably, it will stir deep emotions on both sides of the argument because it raises issues of conscience. I personally agree with the noble Lord, Lord Warner, the noble Baroness, Lady Deech, and my noble friend Lady Cumberlege on state-sponsored fatherlessness. This should not be a matter of party policy and I join my noble friend Lord Howe in calling for this issue to be decided on a free vote across the House. I hope that the Minister will be able to assure us on that when he responds.
	Much of the success in delivering good health adult social care will depend on a well trained and motivated workforce. It is the same in children's services and education. Under the leadership of David Cameron, the Conservative Party has done much research and taken a good, hard look at where we can find solutions to the difficulties that overwhelm so many of the vulnerable in our society. Part of that is our Social Workers' Commission, which has been so kindly mentioned by the noble Earl, Lord Listowel. It was set up by my honourable friend Tim Loughton MP, and I had the great privilege to serve on it. Under the patronage of the noble and learned Baroness, Lady Butler-Sloss, and the noble Lord, Lord Laming, the commission's experts had no affiliation to the Conservative Party, but shared a desire and dedication to inform the debate and to find solutions—the same desire that the noble Baronesses, Lady Pitkeathley and Lady Howarth of Breckland, expressed today. We hope that our report, entitled No More Blame Game—The Future for Children's Social Workers, will stimulate a constructive debate because there is no doubt that children's social workers operate very much at the sharp end of children's services. We will need all their expertise to deliver the best possible outcomes for looked-after children.
	The Children and Young Persons Bill is rightly ambitious for those children who, for the most part, find themselves in the care of the state through no fault of their own. We welcome many of the proposals but, as the right reverend Prelate the Bishop of Leicester said, they are long overdue. I can assure the noble Baroness, Lady Barker, that, like the Liberal Democrat Front Bench, we will give the Government a hard time on anything that falls short on providing the best care. For too long our debates have concentrated on the outrageous number of children in care, 60,000, who are moved from pillar to post, away from all that is comfortable and familiar. That affects not only their emotional well being, but jeopardises their chance of decent qualifications. While I acknowledge that the figures have improved, it is still small wonder that only 12 per cent of looked-after children gained five good GCSEs.
	It is good that the Government are committed to ensuring placement stability in the two years before GCSEs, but placement stability in an area where a child has roots and friendships should be a desired outcome at all stages of a child's life in care. We welcome the Government's intention to listen to children and to young people, regarding important decisions that affect their future. I remember listening to a young girl in care who said that it was so dispiriting always to be talked about rather than talked to. I join the noble Earl, Lord Listowel, in warmly welcoming the Government's commitment to ensure that young people are not forced out of care before they are ready and to provide them with support and guidance for as long as they need it. Never again must we hear from the inspectors of 16 year-olds cast adrift into an uncertain future with all their worldly goods tied up in a black bin liner.
	Is it any wonder that so many of those who leave the care system enter the prison system—failed first by their families and then by the state which professed to care for them? If they slip through the net, we must ensure that they are properly cared for while in custody; that they know that someone still cares for them on the outside; and that we will do all that we can to stop them reoffending. That includes education, vocational skills, communication skills and the arts, so powerfully expressed by the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Massey of Darwen. I so agree with the noble Baroness, Lady Young of Hornsey, about the arts raising much needed levels of self esteem.
	I cannot leave the subject until I mention trafficking. It is a hideous trade, as we have heard so graphically from my noble friend Lord McColl. In March of this year, in our annual International Women's Day debate, and again in June in a debate on trafficking, I mentioned the plight of a particular group of young people who are often overlooked. That is the scandal of young girls who leave the care of the state and are then trafficked within our own borders, mostly for sexual exploitation. These children just disappear. Last year, 48 victims of child trafficking went missing from the care of just three local authorities. That is a shocking figure, and one that we simply cannot ignore.
	It could not possibly be a gracious Speech without an education Bill. We have now had three manifestos, 11 Acts of Parliament, 10 strategy documents, nine Green Papers, eight White Papers and six Secretaries of State, and yet almost half of 11 year-olds cannot read, write and add up properly, and in the past five years key stage 1 results at age seven have flat-lined. In their latest Bill—the Education and Skills Bill—the Government propose to raise the education participation age to 18 by 2015. The desire to ensure basic literacy and numeracy and to create a competitive and well skilled workforce is worthy, and the underlying ambition of the Government is sound. The educational charity Edge has called it a noble objective and went on to ask,
	"who wouldn't support more young people becoming engaged in education, employment and training?".
	However, it feels that it is an initiative that will be doomed to failure unless the Government address why young people drop out in the first place. We share that concern.
	By simply dictating that it will be compulsory to stay in education or training until 18, the Government run the risk of overlooking and thus perpetuating the reason why so many of our young are disenchanted with education—and there are many reasons why they are disillusioned and lack incentives to work. The Joseph Rowntree Foundation pointed out in its excellent report on poverty and social exclusion of December 2006 that it is often because the Government fail to take into account the importance and influence of families and communities in this area. It is therefore hardly surprising that the number of 16 to 18 year-olds not in education, employment or training has gone up under this Government from 160,000 to 220,000, considering that the UK has a higher proportion of children in workless households than any other EU country.
	As the noble Lord, Lord Dearing, so rightly said, compulsion does not seem to be the solution to the real, underlying problem of a lack of skills. The Government's proposal to compel young people to stay in education or training until they are 18, backed by criminal sanctions for failing to do so, is an example of the Government appearing tough on skills deficiencies without being tough on the causes of skills deficiencies. Of course we on these Benches want to see more young people studying and training until they are 18, but the Government's proposal is not well thought out.
	There are problems that must be tackled much earlier on. Sir Paul Judge, the president of the Association of MBAs, says that to get an MBA, the most internationally recognised degree in the world, requires a minimum of 500 hours of classroom teaching. At the other end of the scale, our children spend roughly 6,000 hours in school between the ages of five and 11. If an MBA can be taught in 500 hours, then one would expect that all but children with the most severe learning difficulties could learn how to read in 6,000 hours. Indeed, teachers largely agree that a child should be taught to read and write in less than 250 hours, yet nearly half of children leaving primary school at 11 do not reach the required standard in basic reading, writing and maths, and just over 90 per cent of those below standard in English at age 11 are still below standard at 16. Something in the system is very wrong, and it is tragic because without those basic building blocks all the excitement that education has to offer and the moral imperative to let young people unlock their potential, of which the noble Baroness, Lady Warwick of Undercliffe, spoke, will not be realised.
	The business community recognises that though there is a pressing need for skilled workers, it will not be fixed by forcing people to continue for an extra two years in an education system that has already failed them. Miles Templeman, director general of the Institute of Directors, criticised the proposals for being all about new duties, duties for parents, duties for local authorities and duties for young people, adding,
	"our view is that compulsion is no panacea for early under-achievement".
	The issue is particularly worrying for small businesses. As the daughter of parents who had a small cake shop, I saw at first hand the strain it put on my parents and the few people who worked for them when, for whatever reason, a member of staff was absent. I worry that the compulsion element to accredited training will simply mean that small businesses will not employ 16 year-olds. They might just be the entrepreneurs the noble Baroness, Lady McIntosh of Hudnall, spoke of.
	Like my noble friend Lord Pilkington, I have the highest regard for the noble Lord, Lord Adonis, and do not doubt for one moment his desire to see standards rise and for each child to fulfil their potential. But when the Government have failed at the basics, it is not enough simply to spend more money, pass more laws and add more regulation to fix the effects of the problem and not the cause.
	In a similar fashion, the Government's proposals to institute a diploma scheme to improve vocational training cannot be criticised for their intentions. The reform of vocational learning is an important and worthy goal. We support it but feel that the Government again are going about tackling the issue the wrong way.
	We would never criticise an attempt to create robust, recognisable standards for vocational training, and we see the value of a vocational qualification that reflects the completion of a strong practical course designed to equip young people with the necessary skills to make serious contributions to the workforce.
	In seeking to ensure that diplomas offer the highest possible vocational standard, it is important not to confuse this search with the parallel necessity of ensuring strong academic standards. The new diplomas in academic subjects muddle these two different ideas. As my noble friend Lord Pilkington of Oxenford said in his barnstorming speech, to gain respect vocational qualifications have to stand in their own right. The Government suggest that the new diplomas will focus on science, languages and humanities as broad subjects. That seems to suggest a confusion of emphasis between academic knowledge and rigour and a more practical skills-based approach. I do not want to suggest that skills-based teaching is, or should be, without some sort of academic component. However, we must not let the praiseworthy ambition of reforming vocational learning weaken our attempt to improve academic standards.
	I turn very briefly to apprenticeships. The noble Baroness, Lady Morgan of Huyton, mentioned apprenticeships and how important they were. We will look carefully at the draft Bill because we are concerned that of the current 150,000 apprenticeships, as the noble Baroness, Lady Sharp, said, many are never completed. It is possible to go through a whole apprenticeship without having any practical experience.
	The Government are right to be ambitious for our young people. We look forward to a lively and busy Session, and to playing our part in improving the outcomes of our children and young people by improving government legislation. That is what your Lordships' House does best. As my noble friend Lord Howe said, I have more than just a feeling that along the way a few such improvements may be forthcoming.

Lord Adonis: My Lords, this has been a wide-ranging debate with excellent speeches from all sides of the House. I should tell the noble Lord, Lord Dearing, that it was indeed my ambition as a young teenager to become chairman of British Rail. The great stars in my firmament were Sir Peter Parker and the noble Lord, Lord Marsh. There but for the grace of God I might have gone. Instead I ended up with the much more challenging logistical task of replying to this debate, with its 33 speakers covering a vast spectrum of issues from the Roundhouse to NHS dentists via human fertilisation and the sale of the student loan book. Trying to reply to all of that is like trying to reply to a symphony orchestra with a recorder. Rather than seek to do the impossible I will concentrate in particular on comments made in the debate on the five Bills announced in the gracious Speech in the spheres of health, education and social policy.
	Let me start with the Human Fertilisation and Embryology Bill. It is hard to think of a piece of legislation—encompassing some of the most serious ethical, legal and medical issues of our age—which your Lordships are more fitted by means of expertise and experience to consider.
	The current legislation, the Human Fertilisation and Embryology Act 1990, stems largely from recommendations from a committee chaired by the noble Baroness, Lady Warnock, in the 1980s. The fact that it has stood the test of time so well is a great tribute to the noble Baroness and her colleagues. It is also a tribute in no small part to the noble Baroness, Lady Deech, who for eight years until 2002 chaired the Human Fertilisation and Embryology Authority—a body which, as she said, has been copied worldwide.
	Since the 1990 Act, the House has contributed expertise to help frame and improve the IVF legislative structure in a number of respects. Those include the 2001 regulations that extended the use of embryos to stem cell research, the Human Reproductive Cloning Act 2001, which prohibited reproductive cloning, and the 2002 Stem Cell Committee of the House chaired by the noble and right reverend Lord, Lord Harries.
	More recently, several noble Lords were members of the Joint Committee that scrutinised the draft Human Tissue and Embryos Bill, which is now brought forward in amended form as the Human Fertilisation and Embryology Bill. The Government appreciate the committee's very helpful work and welcome its recommendations. I was glad to hear the noble and right reverend Lord, Lord Harries, describe the Joint Committee and the government response as "a model" of good parliamentary and governmental practice. It has led to the Government to revise their view on a number of issues, as he and other noble Lords recognised in their speeches. In particular, as the House knows, the Government initially proposed merging the Human Fertilisation and Embryology Authority and the Human Tissue Authority to form a single regulator. That proposal was questioned by the Joint Committee because, for reasons set out by the noble and right reverend Lord, Lord Harries, the committee believed that the regulatory oversight provided by the HFEA and the HTA separately was likely to be better than that of a single regulator. We have accepted that key recommendation, among others, and I am glad that our decision was welcomed by the noble Earl, Lord Howe, the noble and right reverend Lord, Lord Harries, and other speakers in the debate.
	The Bill to be brought forward aims to keep regulation abreast of ground-breaking scientific advancements, including embryonic stem cell research for the treatment of serious diseases. The fundamental structure of the 1990 Act, informed by the noble Baroness, Lady Warnock, remains none the less unchanged. Our aim is to regulate the capacity—unforeseen in 1990—to screen embryos for serious genetic diseases and to offer legal recognition for different family forms.
	The Government recognise that there will be a range of opinions in the House on these matters. My noble friend Lord Warner, in particular, alongside the noble Baronesses, Lady Deech and Lady Cumberlege, mentioned the provision for fertility clinics to take account of the child's need for a father. I should make it clear that there is currently no ban on access to assisted reproduction in cases where there will not be a father. The Human Fertilisation and Embryology Act requires that a woman,
	"shall not be provided with treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father)".
	However, that duty is the subject of guidance by the Human Fertilisation and Embryology Authority, which currently states:
	"Where the child will have no legal father the treatment centre is expected to assess the prospective mother's ability to meet the child/children's needs and the ability of other persons within the family or social circle willing to share responsibility for those needs".
	Therefore, the current situation is unclear and the Government, having carefully considered whether research evidence supported the continued reference in primary legislation to a duty on clinicians to give specific attention to the need for a father, concluded that the findings of research in that area tend to show that the factor of prime importance is the quality of parenting, rather than parental gender per se. On balance, therefore, the Government have decided to remove the reference to the need for a father, but to retain in primary legislation a general duty to take account of the welfare of the child. In doing so, we have taken account of the view of the House of Commons Science and Technology Committee in its 2005 report, which says:
	"The requirement to consider whether a child born as a result of assisted reproduction needs a father is too open to interpretation and unjustifiably offensive to many. It is wrong to imply that unjustified discrimination against 'unconventional families' is acceptable".
	I do, however, accept that there are strongly held opinions on this matter, and they will be debated as the Bill proceeds.
	Strong opinions about other issues were also expressed in the debate today. The noble Baroness, Lady Finlay, talked about organ donation, the right reverend Prelate the Bishop of Leicester talked about clone embryos, and the noble Earl, Lord Howe, talked about abortion. The noble Earl asked me whether we would allow a free vote on any proposals to amend the law on abortion. Like him, I hope that this issue does not overwhelm our consideration of other issues as the Bill proceeds, but there will be free votes on the government side on any amendments relating to abortion.

Earl Howe: My Lords, my question was whether the entire Bill, rather than simply the abortion issue, would be subject to a free vote on the government Benches.

Lord Adonis: My Lords, we will take a decision on that before the Bill reaches Committee. However, any amendments relating to abortion will certainly be subject to a free vote on the government side.
	Children in care are a vulnerable group about which Members of the House—not least the noble Earl, Lord Listowel, who addressed this issue with his customary passion today—have long been concerned. We seek to improve the lot of children in care through the Children and Young Persons Bill. There are 60,000 children in care at any one time, the majority of whom are in care because they have suffered abuse or neglect. They deserve the best possible support and nurturing, but as the right reverend Prelate the Bishop of Leicester so rightly said, the reality is that their levels of educational attainment and progression into employment remain deplorably low. They have improved, but are still deplorably low.
	My noble friend Lord Darzi gave statistics earlier in the debate. As the Minister for special educational needs, I should add that 28 per cent of children in care have a statement of special educational needs, compared with the national average of 3 per cent. The startling statistic, which we simply cannot get away from, and which the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Young of Hornsey, mentioned, is that a quarter of adults in prison today have spent time in the care system. The noble Lord, Lord Ramsbotham, talked about the plight of those in custody with his customary eloquence, as did my noble friend Lady Massey. I could not agree more that the quality of education in prisons and young offender institutions has a major bearing on rehabilitation rates. That is why we have increased funding substantially for prison and young offender education. In the past six years, our spending on the education of young people in custody has increased fourfold, alongside significant increases in the number of hours and the quality of provision made available to them.
	My noble friend Lady Massey asked what my department was doing to liaise with other departments on youth justice. Following changes to the machinery of government in June, youth justice policy, including the sponsorship of the Youth Justice Board, became the joint responsibility of the Ministry of Justice and my department. The Youth Justice and Children Unit has now been created. One of its key aims will be to ensure that children and young people in contact with the criminal justice system achieve all five outcomes of Every Child Matters: to be healthy; to stay safe; to enjoy and achieve; to make a positive contribution; and to achieve economic well-being. The joint unit will be launched with external stakeholders at the Youth Justice Board convention on 13 November.
	The Bill seeks to promote good parenting on the part of professionals in the care system, and will provide a stronger voice for each child in care. It will also give great emphasis to ensuring stability for children in care, recognising, as so many speakers have said in the debate, that it is the lack of stability in care placements that goes to the heart of the problems that so many young people in care experience.
	The noble Baroness, Lady Young, emphasised that although the provisions that we have put in place for ensuring that children remain stable in their school placements in years 10 and 11 are good, it would be ideal if we could extend them more widely. I can tell her that part of the role of the designated teacher in respect of children in care, which we are putting on a statutory basis in the Bill, will be to liaise much more closely with social workers, foster carers and others to address the educational needs of children in care, not only in years 10 and 11 but much earlier in their education.
	The noble Baroness, Lady Howarth, raised the serious issue of school exclusions and the impact that they can have on children in care, which is disproportionate compared with the impact on other children. As she will know, the number of permanent exclusions from school has reduced substantially since 1997. But she is right that the disruption caused to the education of children who are excluded, often for compelling reasons, is an issue that we need to address. It is precisely for that reason that we have invested in full educational provision for children who are permanently excluded, which did not exist at all before, and that we provided in legislation enacted by the House in the last Session for support for children who are excluded after the sixth day of temporary exclusions rather than the 16th day of temporary exclusions, which used to be the case. That will mean that fewer children will be on the streets not properly provided for. That reform of provision for children in care will be supported by some £300 million additional investment over the next four years, including additional support for social workers, a group rightly identified by the noble Earl, Lord Listowel, as crucial in all that we do in this area.
	The next education-related Bill is the one that will raise the education participation age to 18. We value the general support given to this reform by noble Lords, but I recognise entirely that it will amount to nothing unless all the component parts—vocational provision and education before 16 and the range of provision available to those aged 16 to 18—are making a reality of near-universal participation by those ages by the time we come to raise the participation age in a phased way, to 17 in 2013 and to 18 in 2015. It is important that the actual raising of the participation age is, by the time it happens, a formal change reflecting practice that is already taking place and is not seen as a new, punitive regime. In that respect, everything that we are doing in the earlier phases of education, right back, as the noble Lord, Lord Dearing, said, to pre-five education, is as important as the changes that we are making beyond 16.
	There have been substantial improvements in rates of achievement before 16. I could trade statistics with the noble Baroness, Lady Morris; we do that from time to time. She quoted some selective statistics, but I could quote back a whole sheaf of statistics, including pointing out that, on all the key measures, standards are significantly higher than they were 10 years ago. The crucial point that we need to make, however, is that if we look at the current rate of improving standards at 16, and the practice of other countries internationally, we believe that this is a sensible next step if we get in place the four key building blocks enabling us to raise the participation age to 18.
	Those four key building blocks are, first, a curriculum and qualifications that provide the right learning opportunity for every young person and which are personalised to their needs, aptitudes and aspirations. That includes a solid grounding for all in functional skills in English, maths and ICT, as well as stretching A-levels and having GCSEs with less focus on coursework and diplomas that mix the best of theoretical and practical learning.
	I am very grateful for the remarks of the noble Lord, Lord Pilkington, on a personal level. We have exchanged remarks across the Chamber over a number of years on the failure of vocational education over the past century—or to be more precise, as the noble Lord, Lord Dearing, put it, over 140 years. Historically, this has been one of our great failings in the education system. The situation has progressively improved over recent years as a result of the growing range of vocational qualifications being taught in schools—reasonably successfully.
	However, we are taking forward a significant improvement of vocational education with the introduction of the new diplomas, which are absolutely focused on the key vocational areas that have historically been of concern to the country and to which the noble Lord, Lord Pilkington, referred. The first five diplomas in construction—the built environment, creative and media technologies, engineering, information technology and society, health and development will be available from next September. From 2009, diplomas in environmental and land-based studies, manufacturing and product design, hair and beauty studies, business administration and finance, and hospitality will be available, and from 2010, diplomas in retail, public services, sport and leisure, and travel and transport will be available. There will be diplomas for all those great national industries where we require young people to be trained specifically. Our projections are that by 2010-11 there will be more than 300,000 learners studying for diplomas, which is 10 per cent of the 14 to 19 year-old population, on the basis of the work being done with the 14 to 19 partnerships which are gearing up to prepare for their introduction next year.
	The second key building block for the reform is, as the noble Lord, Lord Ramsbotham, rightly said, enhanced advice and guidance to help all young people to make the right choices, with clear specifications for local authorities to provide every young person with guidance on the educational choices available to them. Thirdly, there needs to be improved financial support, so that no one is excluded because of costs. That will include an expansion of the successful education maintenance allowance scheme to support a broader range of courses and entry to employment programmes. Fourthly, and vitally, there needs to be enhanced employer engagement, including an expansion of apprenticeships. There has been a substantial increase already in the past 10 years, but there will be an extra 90,000 apprenticeships for young people by 2013, so that work-related routes are much more widely available than at present.
	On additional places—another issue which was raised—declining demographics in this age range mean that there will be little difference in the total number of 16 and 17 year-olds in schools in 2015 compared to this year. There will be a small increase in FE for which we will prepare. This also takes place in the context of massive capital investment in this area. Capital investment in schools will total—

Lord Pilkington of Oxenford: My Lords, I do not expect the Minister to give a definitive reply, but are the Government even prepared to consider putting pressure on industry to contribute to these improved qualifications?

Lord Adonis: My Lords, industry contributes substantially to these qualifications, particularly where they help with apprenticeships. I am sure that will continue to be the case over the coming years. Industry played a key part in helping us to design the diplomas. They have all been designed by industry-led groups in the specific areas being covered by them.
	We believe that in conjunction with the big capital investment which will achieve many of the objectives set out by the noble Lord, Lord Dearing, this is a sensible, incremental reform which will raise our education and skills levels in the way that they need to be raised as we meet the international challenges ahead.
	The Sale of Student Loans Bill is being introduced by the Department for Innovation, Universities and Skills. The student loans book is an asset of £18 billion, which will grow significantly over the next decade. The Government's established policy is not to retain assets unless to do so fulfils a public policy purpose. We believe that in principle the private sector is able to manage the risks associated with this loan book and has an appetite to do so. However, in response to the points made by the noble Lord, Lord Higgins, and my noble friend Lady Warwick on behalf of the universities, let me stress that this is an enabling Bill. The timing of any sales will be at the discretion of the Government and we would obviously carry through such sales only when we believe that they will be advantageous to the taxpayer. I should reiterate that the Government are not altering in any way their policy on student support. Student loans will not become commercial loans. Borrowers with student loans will experience no difference whether their loans are sold or retained in the public sector. The experience of the students will not change at all as a result of these reforms.
	The Health and Social Care Bill was set out more fully by my noble friend Lord Darzi in his opening remarks. By bringing together the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission into one body, we will create a more efficient, integrated regulator, much like the merger of children's services inspectors with Ofsted two years ago. I am glad that this move has been broadly welcomed by the noble Earl, Lord Howe. I agree with him and others speaking in the debate that the culture of an institution is vital to its success and is much more important than the precise legislative provisions we make. I also want to reassure my noble friend Lady Pitkeathley that it is important to retain the expertise of all three predecessor bodies, not least the Commission for Social Care Inspection, in the new organisation. It is central to our policy that that should be the case.
	The noble Earl, Lord Howe, asked where the duties of the Care Quality Commission will extend to PCTs. I can tell him that the commission will publish independent comparative information, including an assessment of the performance of commissioners for both health and adult social care—which means both PCTs and local authorities. We see that as important to maintaining public confidence in the transparency and accountability of commissioners and in how effectively they use public money. However, it is important that the new commission should not duplicate or overlap with the role of strategic health authorities and, as with the current regulators, the Care Quality Commission will not have powers to intervene with PCTs as commissioners. Intervention, including action to develop PCT capability where necessary, will be part of the performance management role of strategic health authorities.
	The noble Earl also asked whether the Care Quality Commission would handle complaints. We have decided that it would not be appropriate for the new regulator to have a role in processing individual health or social care complaints, but rather that it should have a role in looking at the outcomes from complaints and focusing on the standard of complaint handling. However, the detailed requirements of regulation by the Care Quality Commission are likely to require all providers of NHS and adult social care services to have appropriate complaints processes in place, and the boards and senior managers of provider and commissioning organisations will be responsible for ensuring that local complaints arrangements are robust and able to deliver a full and accurate response to anyone making a complaint. I am informed that the responses to the Making Experiences Count consultation, which ran from June to October of this year, indicated overall support from respondents to this approach.
	The Bill will also deliver on the Government's commitment to improve clinical governance in response to Dame Janet Smith's recommendations following the Shipman inquiry, and it will update existing legislation to enhance professional regulation as set out in the recent White Paper, Trust, Assurance and Safety. The noble Baroness, Lady Barker, my noble friend Lord Warner and others raised the issue of the standard of proof in professional regulation, which is a matter that will have to be considered in detail as the legislation goes through. As noble Lords said, the Bill will require all health and social care regulatory bodies to adopt the civil standard of proof during fitness to practise procedures. It will require each regulator to include this requirement in their fitness-to-practise procedure rules, and it will also apply to the new independent adjudicator. I know that concerns have been raised about this, but we believe that the proposal is appropriate and that it is right to proceed in this way because of concern that the use of the criminal standard protects the interests of the professionals regulated by the General Medical Council, the General Optical Council and the Nursing and Midwifery Council at the expense of the patients they are there to serve.
	I also note that 10 of the 13 regulatory bodies covering the regulation of health and social care across the United Kingdom already use the civil standard of proof. Further, it applies in other areas where professionals can potentially lose their livelihood. For example, since 1999 the Independent Police Complaints Commission has employed the civil standard in misconduct proceedings. We believe that this reform is well founded and serves the wider public interest in the delivery of health services.
	As noted by my noble friend Lord Darzi in his opening remarks, the Government are also introducing through this Bill new benefits for expectant mothers which we believe will further improve support for children, particularly those coming from poorer and more vulnerable families. The health and pregnancy grant will be a one-off payment made to all expectant mothers in the final stages of their pregnancy who are ordinarily resident in the United Kingdom. This, like so many of our other reforms as set out in the gracious Speech, builds on 10 years of systematic improvements in the quality of provision available to individuals through our public services. In the specific case of the health and pregnancy grant, it builds on an increase in statutory maternity pay from 26 to 39 weeks, on the creation of a new right for fathers of up to 26 weeks' additional paternity leave and pay, and on the extension of the right to request flexible working to carers of adults.
	A host of other points were raised and I will run through a few briefly before I conclude. The terrible situation in child trafficking, which was raised by the noble Lord, Lord McColl, and the noble Baroness, Lady Morris, is one to which we have been giving a great deal of attention and action. The United Kingdom Government signed the Council of Europe Convention on Action against Trafficking in Human Beings this March. On 3 October last year, the UK Human Trafficking Centre was set up. It plays a key role in co-ordinating work across stakeholders and with its partners delivers a diverse set of programmes, including targeted campaigns, to prevent and reduce the trafficking of human beings.
	The noble Lord, Lord Colwyn, raised the issue of NHS dentists. I promised the noble Lord that my noble friend Lord Darzi would reply to him. When I mentioned this to my noble friend he said that he replies almost weekly to the noble Lord on issues relating to NHS dentistry. But I promise the noble Lord that a still larger torrent of letters will be coming in his direction to deal with the issues that he raised.
	Let me set the wider context. There has been very significant increased investment in NHS dentistry. In this financial year, NHS spending on dentistry is over £407 million more than it was in 2003-04. This has, for example, enabled a 25 per cent increase in undergraduate training places. I could say a great deal more but that is a good news story to tell while recognising that there are still issues, including some of those which the noble Lord raised.
	The noble Lord, Lord Fowler, raised the issue of public health budgets and the attention paid to public health among the many other priorities in the NHS. Ultimately, funding arrangements are a matter for the NHS and primary care trusts. We believe in devolution and the making of decisions, where possible, at the local level. We think it is right that they should be free to prioritise their local funding according to local needs. However, there are key targets for sexual health—an important area mentioned by the noble Lord and in which he has done great work over the years—which must be included in all local PCT delivery plans and we are working on major improvements to the way in which data are collected to improve performance management in this area. PCTs must be able to show what they are doing to improve waiting times, to reduce infections and to deal with these other public priorities.
	Sexual health was one of the six top priorities for the NHS in the last year, as outlined in the NHS planning and priority framework, and the 2007-08 NHS operating framework confirms that sexual health and access to genito-urinary medicine services will continue to be a priority for the NHS in the year ahead.
	In conclusion, let me latch on to the remark of my noble friend Lord Warner, who said that the gracious Speech was a good blend of the visionary and the practical. It also needs to be seen in the context of very significant increases in public investment in all of the key areas of public services over the past 10 years. One can have the greatest visions possible in the world but when it comes to delivery of improved education and improved health, without resources very little will be achieved. While I do not in any way question the commitment of noble Lords opposite to quality public services—I pay tribute to those who have been Ministers in the past and have carried through significant improvements in some areas—if we take health specifically, the fact that in 1997 public investment was £35 billion and today it is £90 billion, rising to £110 billion by 2010-11, is the single strongest testament to the commitment which we on this side of the House have to seeing that quality public services are not simply an aspiration but become a reality for the overwhelming majority of people in our country.
	We recognise that there is still more to do. We are not in any way complacent but this gracious Speech builds on 10 years of sustained investment and reform; it builds on significant improvements in quality; and it is a testament to our commitment to building a more open and more equal society. I commend it to the House.

Baroness Crawley: My Lords, on behalf of my noble friend Lord West of Spithead, I beg to move that the debate be adjourned until Monday, 12 November.
	Moved accordingly, and, on Question, Motion agreed to, and debate adjourned accordingly until Monday next.

Bournemouth Borough Council Bill [HL]

The Chairman of Committees informed the House that, in accordance with Private Business Standing Order 150A (Suspension of Bills), the Bill had been deposited in the Office of the Clerk of the Parliaments together with the declaration of the agent. The Bill was presented and read a first time. It was then deemed to have been read a second time and reported from the Select Committee.

Manchester City Council Bill [HL]

The Chairman of Committees informed the House that, in accordance with Private Business Standing Order 150A (Suspension of Bills), the Bill had been deposited in the Office of the Clerk of the Parliaments together with the declaration of the agent. The Bill was presented and read a first time. It was then deemed to have been read a second time and reported from the Select Committee.

Transport for London (Supplemental Toll Provisions) Bill [HL]

The Chairman of Committees informed the House that, in accordance with Private Business Standing Order 150A (Suspension of Bills), the Bill had been deposited in the Office of the Clerk of the Parliaments together with the declaration of the agent. The Bill was presented and read a first time. It was then deemed to have been read a second time and committed to an Unopposed Bill Committee.

Transport for London Bill [HL]

The Chairman of Committees informed the House that, in accordance with Private Business Standing Order 150A (Suspension of Bills), the Bill had been deposited in the Office of the Clerk of the Parliaments together with the declaration of the agent. The Bill was presented, read a first time, passed though all its remaining stages pro forma and sent to the Commons.
	House adjourned at 5.34 pm.